ERG Leadership Conference - Registration

2021 National ERG Leadership Conference Registration Form

Welcome! We're glad you're joining the conversation. Please provide the following registration information:

First Name: *

Last Name: *

Preferred Pronouns: *

she/her/hers

he/him/his

they/them/theirs

Email: *

Company: *

Job Title: *

Phone: *

Address (please list the address you currently use to receive mail (home or office): *

City: *

Country: *

State or Province:

Zip / Postal Code: *

How did you hear about this event? *

Create Your Password: *

Confirm Your Password: *

If you are a member of an ERG, select which general heading describes the group(s):

Select your first choice of ERG breakout session :

Select your second choice of ERG breakout session:

In-Person Reception: Will you be attending the in-person reception at RTP, NC on October 14 at 5:30 p.m.? *

Why do you think ERGs are important?

What do you hope to gain from the conference?

Are there any topics not listed on the agenda that you would like discussed?

If you have a disability and may require accommodations in order to fully participate, please indicate here:

If you need special accommodations, how would you like to be contacted to discuss your needs?

Select your ticket. Once you complete the registration process, you will be redirected to PayPal's secure payment page for fee-based tickets:

	Required Ticket* You must select one ticket from this section before continuing.		Price
	General Conference Attendee	1	$170

NOTE: You are purchasing a group ticket. Please complete this form on behalf of an attendee and then provide an alternate email below for receiving the group coupon.

Total: 0

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