Please fill out all information for the adult attending.

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* 1. First Name

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* 2. Last Name

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* 3. Your YMCA

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* 4. Your State

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* 5. Your Job Title or Role

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* 6. I am registering as:

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* 7. Number of Years with Youth and Government or the YMCA?

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* 8. Your Email

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* 9. Cell Phone Number

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* 10. Gender

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* 11. Your Correct Pronouns

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* 12. Shirt Size

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* 13. Emergency Contact First Name ?

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* 14. Emergency Contact Last Name ?

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* 15. Emergency Contact Best Phone Number ?

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* 16. List any allergies (Dietary/Medicinal/Environmental/etc...) ?

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* 17. Meal Requests-Please indicate if a specific meal type is requested

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* 18. Other Dietary Requests or Restrictions ?

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* 19. Please let us know of any requests, ideas, or goals you have for the conference .

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