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* 1. First Name (Exactly as you wish it to appear in all printed materials such as nametag)

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* 2. Last Name

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* 3. Your YMCA

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* 4. What is your role or title at your YMCA? Volunteer, Board member, CEO, etc.

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* 5. Correct Pronouns (These will be displayed on your nametag)

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* 6. Shirt Size (All sizes Adult)

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* 7. Street Address

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* 8. City

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* 9. Zip Code

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* 10. Your Email.  Please make sure it is spelled correctly, as this will be the way you receive communication about the program.

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* 11. Cell Phone Number

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* 12. Emergency Contact First Name

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* 13. Emergency Contact Last Name

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* 14. Emergency Contact Best Phone Number

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* 15. Do you plan to attend the dinner and legislative briefing at 5:30pm on February 6th?

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* 16. Please indicate if a specific meal type is requested, select any that apply.

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* 17. Other Dietary Requests or Restrictions

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* 18. Are you planning to stay at the Hampton Inn & Suites hotel? If so, please be aware that the hotel room block is limited, and the dinner and briefing are at that hotel.

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* 19. Do you plan to attend the Advocacy Day meetings on February 7th?

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