CiviCRM - Healthy Futures of Texas

Registration Information

First Name/Primer Nombre *

Last Name/Apellido *

Credentials *

Email Address/Correo Electrónico *

Organization/Organización *

Title/Título

Street Address/Dirección

City/Ciudad *

State/Estado *

Postal Code/Código Postal *

What Region of Texas are you located in?

Phone/Teléfono

Do you have a disability that would benefit from any accommodations? (physical, intellectual, psychiatric, visual, hearing, neurological, or other medical condition)? *

Yes No

If marked yes, are there any accommodations we can make for you?

Sector

Healthcare

Higher Education

K-12 Education

Non-profit

Faith-based Organization

After-School

Gov't/State

Child Welfare

Elected Official

Student

Other

Not In Workforce

How did you hear about this event? (check all that apply)

Online Search

Poster/Flyer

Professional Association

School District

Medical Institution

University

HFTX Email/Newsletter

HFTX Social Media

HFTX Staff Member

HFTX Online Ad

Event Sponsor/Exhibitor

Other (write-in below)

Other way you heard about this event

I am a member of my area's teen pregnancy prevention/adolescent health coalition *

Yes

Unsure

Please enter a full URL beginning with https://linkedin.com

Facebook

Please enter a full URL beginning with https://facebook.com

Twitter

Please enter a full URL beginning with https://twitter.com

Event Fee(s)

If you have a discount code, enter it here

Event registration Fees *

All Access Pass (May 6-9) - $ 600.00: May 6-8 are in person only; May 9 is is virtual

Two Day, In Person (May 6-7) - $ 425.00

Two day in person + one day virtual (May 6-7 & May 9) - $ 350.00

One Day, In Person (May 6 or May 7) - $ 250.00

One day in person + one day virtual - $ 300.00

One Day, Virtual (May 9) - $ 175.00

NOTE: If you selected ALL ACCESS PASS above, your Wednesday workshop is included. Please DO NOT select a workshop below. We will contact you for your workshop selection.

Additional Workshops - In Person Only

Puberty Workshop - It's more than pimples and periods - $ 150.00

Advanced Facilitation Skills - $ 150.00

Facilitating Sex Ed: A Deeper Dive - $ 150.00

- none -

Contraception Education - In Person Only

FULL: Contraceptive Counseling Lunch (May 7, 12:30-1:30 - Open to all) - $ 0.00

IUD Training (May 6, 4-6pm - Clinicians only) - $ 0.00

Total

Payment Options

Payment Method

Credit Card I will send payment by check.

My billing address is the same as above

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Province

Postal Code

Food Preferences

I have special dietary requests

Yes No

My special dietary requests

Vegetarian Vegan Gluten-Free

We are unable to accommodate food preferences beyond those listed here.

Demographic Information

Age Range

Under 18 18-24 25-34 35-44 45-54 55-64 65 and older

Gender

Female Male Nonbinary/Genderqueer Transgender Female Transgender Male Prefer not to answer

Race/Ethnicity

Asian Black or African American Hispanic or Latinx Native American or Indigenous Pacific Islander White Bi-Racial, option to specify below Multi-racial, option to specify below None of the above, option to specify below Prefer not to disclose

Race/Ethnicity (Fill In)

Healthy Futures of Texas – 13th Annual Symposium

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