Registrant Type Please select Family Voices Affiliate Organization Conference Registrant Other Family Organization Conference Registrant Other Conference Registrant Pre-conference ONLY Registrant
First Name
Last Name
Email
Organization
Job Title
Preferred Phone Number
Street Address
City
State
Zip Code
Which of the following best describes your role in attending the conference? (select all that apply) Leader or staff member of an agency or organization that helps children and youth with special health care needs (CYSHCN) and their families Educator, researcher/academic, health/education provider or specialist, consultant, or other professional who works with CYSHCN and their families Parent/family member/caregiver of a CYSHCN Youth/Young adult with special health care needs (SHCN) Other person with lived experience (e.g., adult with a disability)
What organization(s) are you from? (select all that apply) Family Voices Affiliate Organization (FVAO) Family-to-Family Health Information Center (F2F) Tribal or Territorial Organization Parent to Parent (P2P) Parent Center (PTI or CPRC) Other family organization State Title V Other MCHB-funded organization Other professional organization Other CYSHCN stakeholder I am not affiliated with an organization
Is this your first time attending a national conference with Family Voices? Please select Yes No
Spanish interpretation will be provided for all live-streamed sessions. Do you plan to take advantage of this? Please select Yes No
Do you require special assistance, accommodations, or interpretation in a language other than English or Spanish? Please select Yes No
Please describe the assistance or accommodations that you need:
What is your race/ethnicity? (select all that apply) Asian Black or African American Hispanic/Latino and/or LatinX Indigenous, Native American, or Alaska Native Middle Eastern Native Hawaiian or Pacific Islander White I prefer not to say An identity not listed here (please specify)
Please specify:
What language(s) do you speak at home? (select all that apply) English Spanish Chinese Tagalog Vietnamese Arabic Another language (please specify)
Another language (please specify):
Are you a speaker/presenting at this conference? Please select No, I am not presenting Yes, I will be presenting at the conference
PAYMENT METHOD Please select Credit Card (Stripe) Check Purchase Order No Payment
Purchase Order Number
Billing Email Address
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