NCRC #36 Registration Form!
First Name / Prenom *
Please enter your first name here.
Your answer
Last Name / Nom *
Please enter your last name here.
Your answer
Station / Independent *
Your answer
Role (Staff/Volunteer/Community Member) / Rôle (personnel/bénévole/membre communautaire) *
Your answer
Mailing Address / Addresse *
Your answer
Email Address / Courriel électronique *
Your answer
Phone Number / Numero de Téléphone *
Example: (123) 123-4567
Your answer
Please select an option: / Veuillez choisir une option: *
City / Ville *
Your answer
What dates will you be attending? / Sélectionnez les dates
Method of Payment? | Méthode de paiement? *
Accommodations | Hébergement
Dietary Info / Information diététique
Your answer
Emergency Contact Information (Name and Phone Number) / En cas d'urgence (Nom et numéro de téléphone) *
Your answer
Are you interested in presenting at the conference?
If yes/maybe, what topic(s) would you like to present on? What are your areas of skill & expertise?
Your answer
Please select if any of these broad areas apply
Is there anything else that we should know about?
What best describes me?
How will you be travelling? / Comment allez-vous voyager ?
Do you need assistance in arranging transportation? (including from the train station or airport, or car pooling)
Your answer
Travelling From
Have you attended the NCRC before?
Your answer
Have you applied for NCRA Funding?
What areas of the conference most interest you?
Questions, Comments, and/or Concerns?
Your answer
Are you paying by paypal or credit? *
If so, please visit this link to do so by visiting and selecting the appropriate item from the drop down menu above the PayPal logo in the middle of the page.
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