Registration 2017 NBSLA Conference Registration 2017 NBSLA Conference Registration Are you a new advisor? Yes No Is this your first NBSLA Conference? Yes No How many Advisors are attending from your school? 12 (additional $200.00) Advisor School Name * School Address * (Address, City, Province, Postal Code) School Phone Number * (e.g. 123-456-7890) First Name * Last Name * Email * Home Phone * (e.g. 123-456-7890) Mobile Phone * (e.g. 123-456-7890) Medicare Number * Emergency Contact Name * Emergency Contact Phone Number * (e.g. 123-456-7890) Allergies * (Please list or enter N/A if none) Room Sharing * (Click here to choose)I will share a room with another advisor.I will not be sharing a room with another advisor. (Additional $130.00 charge applies) Advisor T-Shirt Size ($10.00) Small Medium Large Extra Large 2XL Advisor #2 School Name * School Address * (Address, City, Province, Postal Code) School Phone Number * (e.g. 123-456-7890) First Name * Last Name * Email * Home Phone * (e.g. 123-456-7890) Mobile Phone * (e.g. 123-456-7890) Medicare Number * Emergency Contact Name * Emergency Contact Phone Number * (e.g. 123-456-7890) Allergies * (Please list or enter N/A if none) Room Sharing * (Click here to choose)I will share a room with another advisor.I will not be sharing a room with another advisor. (Additional $130.00 charge applies) Advisor T-Shirt Size ($10.00) Small Medium Large Extra Large 2XL How many Students are attending the conference? 12 (additional $200.00 per student)3 (additional $200.00 per student)4 (additional $200.00 per student)5 (additional $200.00 per student)6 (additional $200.00 per student) Student #1 First Name Last Name Gender Male Female Email Address Phone Number Medicare Number Emergency Contact Name Emergency Contact Number Age Grade Student Position (e.g. Student Council or Leadership Team, etc.) Allergies Room Sharing (Click here to choose)I will share a room with a school-mate. (same-gender)I will not be sharing a room with a school-mate. Student T-Shirt Size ($10.00) SmallMediumLargeExtra Large2XL Student #2 First Name Last Name Gender Male Female Email Address Phone Number Medicare Number Emergency Contact Name Emergency Contact Number Age Grade Student Position (e.g. Student Council or Leadership Team, etc.) Allergies Room Sharing (Click here to choose)I will share a room with a school-mate. (same-gender)I will not be sharing a room with a school-mate. Student T-Shirt Size ($10.00) SmallMediumLargeExtra Large2XL End Section Student #3 First Name Last Name Gender Male Female Email Address Phone Number Medicare Number Emergency Contact Name Emergency Contact Number Age Grade Student Position (e.g. Student Council or Leadership Team, etc.) Allergies Room Sharing (Click here to choose)I will share a room with a school-mate. (same-gender)I will not be sharing a room with a school-mate. Student T-Shirt Size ($10.00) SmallMediumLargeExtra Large2XL End Section Student #4 First Name Last Name Gender Male Female Email Address Phone Number Medicare Number Emergency Contact Name Emergency Contact Number Age Grade Student Position (e.g. Student Council or Leadership Team, etc.) Allergies Room Sharing (Click here to choose)I will share a room with a school-mate. (same-gender)I will not be sharing a room with a school-mate. Student T-Shirt Size ($10.00) SmallMediumLargeExtra Large2XL End Section Student #5 First Name Last Name Gender Male Female Email Address Phone Number Medicare Number Emergency Contact Name Emergency Contact Number Age Grade Student Position (e.g. Student Council or Leadership Team, etc.) Allergies Room Sharing (Click here to choose)I will share a room with a school-mate. (same-gender)I will not be sharing a room with a school-mate. Student T-Shirt Size ($10.00) SmallMediumLargeExtra Large2XL End Section Student #6 First Name Last Name Gender Male Female Email Address Phone Number Medicare Number Emergency Contact Name Emergency Contact Number Age Grade Student Position (e.g. Student Council or Leadership Team, etc.) Allergies Room Sharing (Click here to choose)I will share a room with a school-mate. (same-gender)I will not be sharing a room with a school-mate. Student T-Shirt Size ($10.00) SmallMediumLargeExtra Large2XL End Section reCAPTCHA Δ
