NERAASA 2024 Registration Form
Please use one form per person registering
Name
*
First Name
Last Name
Name on your badge
Email
*
example@example.com
Area
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Please check all that apply
I would like to be a panel moderator or timer
I would like to participate in a panel discussion
I have attended NERAASA before
I have been a NERAASA presenter before
I am interested in a volunteer opportunity
Service Position
GSR/Alternate GSR
DCM/Alternate DCM
DCMC/Alternate DCMC
District Committee
Area Committee
Area Officer
Delegate/Alternate Delegate
Central office/Intergroup
Other
If you have accessability needs, please note below
Translation Requests
ASL
French
Russian
Spanish
Roundtables - which roundtable do you plan to attend
How would you like to receive your NERAASA documents?
Electronic only (email or QR code)
Printed
Are you a Past Delegate?
Yes
No
If you have special dietary needs please specify here
Event Registration and Meals
*
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NERAASA 2024 Registration
Weekend registration
$
35.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
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