2016 Supporter Conference Registration

Thank you so much for registering for the 2016 Supporter Conference which will take place Friday, July 22 - Sunday, July 24, 2016 in Orlando, FL. We are so excited to meet you and equip you with tools necessary to bring TWLOHA's message of hope, love, help, and healing to your community. Please complete the form below in it's entirety. A separate form will be required for each attendee. Unfinished forms will not be processed so be sure to fill in all questions and hit "SUBMIT" when you are finished. Thanks again!

With Hope,
TWLOHA

CONTACT INFORMATION
Please provide us with your contact information.

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1. Please provide conference attendee's contact information:

Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Country: *

Email Address: *

Phone Number: *

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2. Age of conference attendee on first day of conference (July 22, 2016)

(Supporters who are at least 16 years of age as of July 22, 2016 are more than welcome to attend so long as they are accompanied by a parent or guardian over 21 years of age. Supporters 18 and older are not required to be accompanied.)

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3. Gender:

Male

Female

Other

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4. If you're currently in college, please identify your year as of Fall 2016. Mark N/A if you are not a student:

Freshman

Sophomore

Junior

Senior

N/A

Other (please specify)

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5. Please provide your school's information:

School

City/Town:

State:

Country:

Website:

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6. Are you a licensed mental health or health care provider seeking CEU's?

Yes

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7. If you are seeking CEU's please list your license number and state it was issued in.

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8. Are you currently involved in an Active TWLOHA UChapter?

Yes

If yes, Chapter and Leadership Role (President, VP, etc) or if you are a Member:

PERSONAL INFORMATION
This section of the conference application will ask some personal questions regarding your current mental health. This conference will cover some heavy topics that may be triggering to some people. Our attendee's health is of the utmost importance. Please answer these questions as honestly as you can. The answers you provide will be kept strictly confidential and will only be seen by the conference directors.

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9. Please note: Due to the nature of the issues presented in this conference, some of the material discussed may be intense and/or potentially triggering. We suggest consulting with your mental health professional before coming to this conference. If detailed discussions of certain issues may be harmful to your current recovery process, we recommend not attending at this time.

I have read and understand the above statement (please sign by typing in your full name):

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10. Are you currently or have you previously struggled with any of the following?
(Please check all that apply)

Anxiety

Depression

Eating Disorder

Self-Injury

Thoughts of Suicide

Trauma

Addiction

None of These

Other (please specify)

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11. If yes, are you currently receiving or have you previously received counseling/treatment from a mental health professional for the issue(s) stated above?

Yes

Why or Why Not?

GENERAL
This section of the application is just our opportunity to learn more about why you are attending the conference.

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12. What do you hope to learn while you are at the conference?

REGISTRATION
In this section we will complete the registration process. Please be sure to follow all instructions. Applications will not be accepted without payment.

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13. Please register me for:

General Registration: $350.00

Student Registration: $300.00

TWLOHA Soirée + Social (Banquet Dinner): Saturday, July 23, 2016 - FREE

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14. If you haven't already, please use the link below to pay for your conference registration:

https://www.classy.org/lake-buena-vista/events/supporter-conference-16/e79250

CANCELLATION POLICY: Due to the limited capacity for this event, no refunds will be issued due to cancellation. If you are unable to attend this event, please notify us in writing prior to the event.

Once you have completed the registration, please provide your confirmation code below:

FUNDRAISING:

You can also fundraise to up to $350 conference fee. To start a fundraising page, please copy and past the following link into a new browser window: https://www.classy.org/lake-buena-vista/events/supporter-conference-16-fundraising/e79282

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15. Do you have any special needs that require special accommodations so you can fully enjoy the conference?

Yes

If yes, please explain:

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16. I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand that any misrepresentation of myself, or the information provided, will result in disqualification from the 2016 Supporter Conference.

Signed (please enter your full name):

**TWLOHA reserves the right to review and deny any registration to ensure the safety and health of all conference attendees. If you have any questions, please contact conference@twloha.com**

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1. Please provide conference attendee's contact information:

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3. Gender:

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4. If you're currently in college, please identify your year as of Fall 2016. Mark N/A if you are not a student:

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5. Please provide your school's information:

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6. Are you a licensed mental health or health care provider seeking CEU's?

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7. If you are seeking CEU's please list your license number and state it was issued in.

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8. Are you currently involved in an Active TWLOHA UChapter?

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10. Are you currently or have you previously struggled with any of the following? (Please check all that apply)

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11. If yes, are you currently receiving or have you previously received counseling/treatment from a mental health professional for the issue(s) stated above?

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12. What do you hope to learn while you are at the conference?

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13. Please register me for:

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15. Do you have any special needs that require special accommodations so you can fully enjoy the conference?

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16. I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand that any misrepresentation of myself, or the information provided, will result in disqualification from the 2016 Supporter Conference.Signed (please enter your full name):

10. Are you currently or have you previously struggled with any of the following?
(Please check all that apply)

16. I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand that any misrepresentation of myself, or the information provided, will result in disqualification from the 2016 Supporter Conference.

Signed (please enter your full name):