2024 Forum - Lead Presenter Registration Form

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Form must be completed by 5:00 pm EST, Monday, December 11, 2023

Please use this form for registration for the 2024 National Leadership Forum.

READ INSTRUCTIONS CAREFULLY

This registration form is only to be completed by an official 2024 Forum Lead Presenter.

If you have co-presenters, they are to complete the PDF registration form. Please do not share this form with any other coalition member. All forms will be cross referenced with the master lead presenter list.

For any questions, contact CADCA's event team - (703) 706-0560 ext. 253 or email events@cadca.org

Training Session Title *

CADCA's Waiver of Liability

As a requirement to attend a CADCA Training Event, attendees must acknowledge CADCA’s Waiver of Liability.

Click to Read CADCA's Waiver of Liability

Checking This Box Indicates Agreement With The Terms And Conditions Outlined In CADCA's Waiver Of Liability.

Vaccination is not a requirement to attend Forum

I accept and in agreement with the terms outlined in CADCA's Waiver of Liability

Attendee Prefix

Please use proper case. (Example: Ann vs ann or ANN)

Mrs.

Ms.

Mr.

Miss

Dr.

Other:

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Attendee First Name *

Please use proper case. (Example: Ann vs ann or ANN)

Attendee Last Name *

Please use proper case. (Example: Smith vs smith or SMITH)

Attendee Suffix

Attendee Email Address *

You will not recieve a recipt or confirmation of registration/housing arrangments without an email address.

Is this your FIRST TIME attending a CADCA National Leadership Forum? *

Yes

Are you attending SAMHSA's Prevention Day, Monday, Jan 29th? *

Yes

Attendee Coalition/Organization Name *

Please use proper case and complete with the full name of the organization.

Coalition Address Line 1 *

Please use proper case.

Coalition Address Line 2

Please use proper case.

Coalition City *

Please use proper case.

Coalition State Code *

Coalition US Territory Code or OTHER

Please only select this option if you reside in American Somoa, Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Palau, Puerto Rico or the US Virgin Islands.

Coalition Country

Please type your Country in proper case. For example, United States.

Attendee Zip Code *

Attendee Primary or Mobile Phone *

Please provide the mobile/primary phone number in the following format: (XXX) XXX-XXXX

Emergency Name and Phone Number *

Please provide the name and direct phone number for someone not attending the conference.

Dietary Restrictions or Physical Disability Requirements

Please provide any informaiton on any special needs you might have while atttending the conference.

Should I have any questions regarding my registration, I know that I must contact the CADCA office by emailing the events team at events@cadca.org. *

Yes

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