National Social Justice Summit Registration Form Thank you for your interest in our inaugural summit! We can't wait to meet you. National Social Justice Summit Registration Form Thank you so much for your interest in our Summit! Please fill out your info below. We can't wait to meet you. "*" indicates required fields Step 1 of 3 33% Start off by telling us your name* First Last Organization/Company* Title* Email* Enter Email Confirm Email Phone*Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Please list any accessibility needs you'd like us to be aware of.*If none, please put "N/A." How did you hear about the National Social Justice Summit?* Social Media TechBridge Email Word of mouth/TechBridge network/friends Other What track are you interested in?*For breakout room assignment. Social Justice Advocate Track - How data and technology can amplify social justice advocacy efforts Corporate Track - Corporate Social Responsibility and Pro Bono Law Support of Social Justice Work with technology in mind Select your ticket here:*The in-person event will be held in Atlanta, Georgia, and the virtual event program will be hosted on Pacific Time (PT). In-Person Ticket - $99 Virtual Ticket - $49 Great choice! Now, please let us know about any dietary restrictions you have:*We will make an effort to accommodate dietary needs wherever possible! None Kashrut/Kosher Halal Vegetarian Vegan Gluten Free Do you have any allergies we need to know about?*Please list any allergies you want listed on your contact form. If you don't have any, please put "N/A." Preferred Pronouns*This will be listed on your name badge. he/him/his she/her/hers they/them/theirs sie/hir/hirs Other Emergency Contact NameThis information is for our internal use only and will not be shared. First Last Emergency Contact Phone NumberGreat choice! Now, is your mailing address the same as above?* Yes No Mailing Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code 3% Credit Card Processing Fee* Price: $0.00 Almost done! Your total amount is: Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Security Code Cardholder Name Help us Break the Cycle of Generational Poverty Help us Break the Cycle of Generational Poverty
