Member Registration for Hazing Prevention Institute

How many individuals are you registering?

Bronze Members - up to 2 registrations

Silver Members - up to 4 registrations

Gold Members - up to 6 registrations

Registration(s) *

Tell us about first person being registered:

If you are registering additional people, you will provide their information further down in the form. (You may register up to six individuals using this form.)

Name *

First

Last

Email *

Cell Phone *

Institution/Organization *

Job Title or Volunteer Role *

Pronouns

Accessibility needs, allergies and/or dietary needs

Tshirt Size (Unisex) *

Now provide information for the additional people you are registering

Name, Person 2 *

First

Last

Email, Person 2 *

Title/Role, Person 2 *

Pronouns, Person 2

Accessibility needs, allergies and/or dietary needs for Person 2

Tshirt Size (Unisex), Person 2 *

Name, Person 3 *

First

Last

Email, Person 3 *

Title/Role, Person 3 *

Pronouns, Person 3

Accessibility needs, allergies and/or dietary needs for Person 3

Tshirt Size (Unisex), Person 3 *

Name, Person 4 *

First

Last

Email, Person 4 *

Title/Role, Person 4 *

Pronouns, Person 4

Accessibility needs, allergies and/or dietary needs for Person 4

Tshirt Size (Unisex), Person 4 *

Name, Person 5 *

First

Last

Email, Person 5 *

Title/Role, Person 5 *

Pronouns, Person 5

Accessibility needs, allergies and/or dietary needs for Person 5

Tshirt Size (Unisex), Person 5 *

Name, Person 6 *

First

Last

Email, Person 6 *

Title/Role, Person 6 *

Pronouns, Person 6

Accessibility needs, allergies and/or dietary needs for Person 6

Tshirt Size (Unisex), Person 6 *

Comments (if needed)