Home Form LGBT Health and Wellness Conference registrationLGBT Health and Wellness Conference Registration Name* First Last CredentialsProfessionEmail* Phone*Registration type*DMU student, faculty, preceptor, clinical instructor, or staffGeneral registration (administration, community members, non-clinical support staff, etc.)Healthcare professionals (physicians, nurses, social workers, etc.)Early bird pricing through February 22!Do you plan on submitting an abstract?*NoYes, I will submit an abstract laterYes, I will submit an abstract nowAbstractDue to limited oral presentation time spots, you will be notified four (4) weeks prior to the activity if your abstract was approved.Abstract titlePresenting author* First Last Additional author(s)FirstLast Upload abstractAbstract category*PreventionMental healthCultural Competency (Including Education and 101 on LGBT)Quality of Life/WellnessSurveyI am aware of the health inequities within the LGBT community.*Not AwareSomewhat AwareVery Much AwareMy comfort level in working with the LGBT community is:*Not ComfortableSomewhat ComfortableVery ComfortableI use LGBT friendly word, actions, and behaviors when working with the community:*NeverSometimesAlwaysI am aware of LGBT resources and others to collaborate in my community:*NoSomeYesOther informationDietary requirement*NoneVegetarianGluten freeIf you have a disability please list any auxiliary aids or services needed.Do you have any questions or topics for presenters you'd like them to address at the conference? Please include the presenter's name or presentation topic.Emergency contact (optional)Name First Last RelationshipPhonePaymentHow would you like to pay?*Online (credit card)Mail a checkTotal $0.00 Credit CardAmerican ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20162017201820192020202120222023202420252026202720282029203020312032203320342035 Expiration Date Security Code Cardholder Name Billing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code This iframe contains the logic required to handle AJAX powered Gravity Forms.