Language
English (US)
Spanish (Latin America)
Member Registration Form
Primary Contact Name (name of person filling out this form)
*
First Name
Middle Name
Last Name
I am registering as (select one)
*
Please Select
Worker from Worker Center
Staff from Member Organization
Facilitator
NDLON Board Member
DALE Campaign Participant
Radio Jornalera Participant
Health & Safety Participant
Youth Participant
Raffle Winner
Please remember that each organization is allotted four slots. For each registrant, please let us know if you are a staff or worker. If you were given additional slots, please indicate if you are registering as part of the NDLON Board, Facilitator, DALE campaign, Radio Jornalera project, Raffle Winner, Health & Safety campaigns, or Youth Groups.
Your role/position/title in your Organization
*
Name of your Organization
*
Please Select
American Friends Service Committee (Newark, NJ)
ARISE Chicago
Arriba Las Vegas
Building One Community
CARECEN-LA
Casa de Maryland
Casa Freehold
Casa Latina
Catholic Charities (Yonkers)
Center for Worker Justice of Eastern Iowa
Centreville Labor Resource Center
Centro Cultural de Mexico
Centro Humanitario Para Los Trabajadores
Centro Laboral de Graton
Chelsea Collaborative
Coalition for Immigrant Freedom
Community Action Board of Santa Cruz
Community Resource Center
Comunidades Unidas
COPAL
CRECEN
Cross Cultural Council Laguna Beach
Day Worker Center of Mountain View
Dignidad Obrera
Dolores Street Community Services
Don Bosco Workers Center
El Centro del Inmigrante
El Centro Cultural de Mexico
El Centro Hispano
El Sol - Jupiter's Neighborhood Resource Center
ERC /San Diego Day Labor Center
Escucha Mi Voz Iowa
Esperanza Community Center
Familias Unidas en Accion, New Orleans Louisiana
Fe y Justicia Worker Center
Freeport Workers Justice Center
Hope of the Valley
Immigrant Alliance for Justice and Equity (IAJE)
Immigrant Solidarity Casa DuPage
Latin American Coalition
Latino Union of Chicago
Legal Aid Justice Center (Immigrant Advocacy Program)
Malibu Community Labor Exchange
Miami Workers Center
Mission of St. Joan of Arc (Philadelphia Workers Association)
Monument Impact
Multicultural Institute
National Day Laborer Organizing Network (NDLON)
Neighbors Link
New Immigrant Community Empowerment (NICE)
New Labor
New Orleans Worker Center for Racial Justice
Pasadena Job Center
Pomona Economic Opportunity Center
SALVA
Southside Day Labor Center
Street Level Health Project
Tonatierra
Trabajadores Unidos de Washington DC
Unidad Latina en Acción (CT)
Unidad Latina en Acción NJ
United Community Center of Westchester
VIVA Inclusive Migrant Network
Voces de la Frontera
VOZ Worker's Rights & Education Project
WeCount!
Wind of the Spirit
Women Working Together (Florida)
Workers Defense Project
Workers' Justice Project
Workplace Project
What is/are your pronoun(s)?
*
He/him
She/her
They/them
Other
Your preferred name/nickname
Your age
*
Your Work Email
*
example@example.com
Your Personal Phone Number
*
Please enter a valid phone number.
Your Organization's Phone Number
*
Please enter a valid phone number.
Your Organization Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Interpretation needs
*
Please Select
I need Spanish to English interpretation
I need English to Spanish interpretation
I want to volunteer to interpret
None
Dietary needs
Please Select
Vegetarian
Vegan
Kosher
Gluten-free
None
Dietary needs
*
Vegetarian
Vegan
Kosher
Gluten-free
None
Other
If you have any food allergies, accessibility, or accommodations request, please indicate below
Do you require lodging?
*
Please Select
Yes
No
Please indicate below if there is someone specific you would like to room with. We will be staying in college dorm rooms where the setup are suites, either as a suite of 4 with 2 people sharing a room or a suite of 2 rooms, where each person has their own room. We will do our best to accommodate your request.
If you have any special room request due to medical or any other personal reasons, please let us know below. We will follow up with you to figure out the best way to accommodate request.
Do you require a flight?
*
Please Select
Yes
No
Please add your date of birth
*
-
Month
-
Day
Year
Date
Gender on your ID (for flights)
*
Please Select
Female
Male
Unspecified
Undisclosed
What city/state are you departing from? (Please include a preferred airport)
*
Please include name of airport if you have the information
Please indicate date of departure
*
-
Month
-
Day
Year
Date
Preferred departure time
*
Please Select
Early morning
Midday
Afternoon
Evening
Please indicate date of return
*
-
Month
-
Day
Year
Date
Preferred return time
*
Please Select
Early morning
Mid-day
Afternoon
Evening
Program ends at 1pm, suggested return flights are after 4pm on Friday, June 7th
If available, include your seat preference (please remember that your preference might not be available)
*
Please Select
Aisle
Middle
Window
If you have a flight you would like to book please add the link below, we will do our best to accommodate (please also add airline[s] and frequent flyer ID/account number[s] if you want us to register that information when booking).
I am registering
*
Only myself
Myself and other people in my organization
How many are you registering in total? (Please include yourself in the total count)
*
Please include yourself in the total count
Participant 1
Name
*
First Name
Middle Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
I am registering as (select one)
*
Worker from Worker Center
Staff from Member Organization
Facilitator
NDLON Board Member
DALE Campaign Participant
Radio Jornalera Participant
Health & Safety Participant
Youth Participant
Raffle Winner
Job title (if the participant is a staff member)
Participant pronoun(s)
*
He/him
She/her
They/them
Other
Preferred name/nickname
Age of participant
*
Interpretation needs
*
Please Select
I need Spanish to English interpretation
I need English to Spanish interpretation
I want to volunteer to interpret
None
Dietary needs
Please Select
Vegetarian
Vegan
Kosher
Gluten-free
None
Dietary needs
*
Vegetarian
Vegan
Kosher
Gluten-free
None
Other
If they have any food allergies, accessibility, or accommodations request, please indicate below
Do they require lodging?
*
Please Select
Yes
No
Please indicate below if there is someone specific they would like to room with. We will be staying in college dorm rooms where the setup are suites, either as a suite of 4 with 2 people sharing a room or a suite of 2 rooms, where each person has their own room. We will do our best to accommodate their request.
If they have any special room request due to medical or any other personal reasons, please let us know below. We will follow up with you to figure out the best way to accommodate the request.
Do they require a flight?
*
Please Select
Yes
No
Please add their date of birth
*
-
Month
-
Day
Year
Date
Gender on their ID (for flights)
*
Please Select
Female
Male
Unspecified
Undisclosed
What city/state are they departing from? (Please include a preferred airport)
*
Please include name of airport if you have the information
Please indicate date of departure
*
-
Month
-
Day
Year
Date
Preferred departure time
*
Please Select
Early morning
Midday
Afternoon
Evening
Please indicate date of return
*
-
Month
-
Day
Year
Date
Preferred return time
*
Please Select
Early morning
Mid-day
Afternoon
Evening
Program ends at 1pm, suggested return flights are after 4pm on Friday, June 7th
If available, include their seat preference (please remember that their preference might not be available)
*
Please Select
Aisle
Middle
Window
If they have a flight that they would like to book, please add the link below, we will do our best to accommodate (please also add airline[s] and frequent flyer ID/account number[s] if they want us to register that information when booking).
Do you need to register additional participants?
*
Please Select
Yes
No
Participant 2
Name
*
First Name
Middle Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
I am registering as (select one)
*
Worker from Worker Center
Staff from Member Organization
Facilitator
NDLON Board Member
DALE Campaign Participant
Radio Jornalera Participant
Health & Safety Participant
Youth Participant
Raffle Winner
Job title (if the participant is a staff member)
Participant pronoun(s)
*
He/him
She/her
They/them
Other
Preferred name/nickname
Age of participant
*
Interpretation needs
*
Please Select
I need Spanish to English interpretation
I need English to Spanish interpretation
I want to volunteer to interpret
None
Dietary needs
Please Select
Vegetarian
Vegan
Kosher
Gluten-free
None
Dietary needs
*
Vegetarian
Vegan
Kosher
Gluten-free
None
Other
If they have any food allergies, accessibility, or accommodations request, please indicate below
Do they require lodging?
*
Please Select
Yes
No
Please indicate below if there is someone specific they would like to room with. We will be staying in college dorm rooms where the setup are suites, either as a suite of 4 with 2 people sharing a room or a suite of 2 rooms, where each person has their own room. We will do our best to accommodate their request.
If they have any special room request due to medical or any other personal reasons, please let us know below. We will follow up with you to figure out the best way to accommodate the request.
Do they require a flight?
*
Please Select
Yes
No
Please add their date of birth
*
-
Month
-
Day
Year
Date
Gender on their ID (for flights)
*
Please Select
Female
Male
Unspecified
Undisclosed
What city/state are they departing from? (Please include a preferred Airport)
*
Please include name of airport if you have the information
Please indicate date of departure
*
-
Month
-
Day
Year
Date
Preferred departure time
*
Please Select
Early morning
Midday
Afternoon
Evening
Please indicate date of return
*
-
Month
-
Day
Year
Date
Preferred return time
*
Please Select
Early morning
Mid-day
Afternoon
Evening
Program ends at 1pm, suggested return flights are after 4pm on Friday, June 7th
If available, include their seat preference (please remember that their preference might not be available)
*
Please Select
Aisle
Middle
Window
If they have a flight that they would like to book please add the link below, we will do our best to accommodate (please also add airline[s] and frequent flyer ID/account number[s] if they want us to register that information when booking).
Do you need to register additional participants?
*
Please Select
Yes
No
Participant 3
Name
*
First Name
Middle Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
I am registering as (select one)
*
Worker from Worker Center
Staff from Member Organization
Facilitator
NDLON Board Member
DALE Campaign Participant
Radio Jornalera Participant
Health & Safety Participant
Youth Participant
Raffle Winner
Job title (if the participant is a staff member)
Participant pronoun(s)
*
He/him
She/her
They/them
Other
Preferred name/nickname
Age of participant
*
Interpretation needs
*
Please Select
I need Spanish to English interpretation
I need English to Spanish interpretation
I want to volunteer to interpret
None
Dietary needs
Please Select
Vegetarian
Vegan
Kosher
Gluten-free
None
Dietary needs
*
Vegetarian
Vegan
Kosher
Gluten-free
None
Other
If they have any food allergies, accessibility, or accommodations request, please indicate below
Do they require lodging?
*
Please Select
Yes
No
Please indicate below if there is someone specific they would like to room with. We will be staying in college dorm rooms where the setup are suites, either as a suite of 4 with 2 people sharing a room or a suite of 2 rooms, where each person has their own room. We will do our best to accommodate their request.
If they have any special room request due to medical or any other personal reasons, please let us know below. We will follow up with you to figure out the best way to accommodate the request.
Do they require a flight?
*
Please Select
Yes
No
Please add their date of birth
*
-
Month
-
Day
Year
Date
Gender on their ID (for flights)
*
Please Select
Female
Male
Unspecified
Undisclosed
What city/state are they departing from? (Please include a preferred Airport)
*
Please include name of airport if you have the information
Please indicate date of departure
*
-
Month
-
Day
Year
Date
Preferred departure time
*
Please Select
Early morning
Midday
Afternoon
Evening
Please indicate date of return
*
-
Month
-
Day
Year
Date
Preferred return time
*
Please Select
Early morning
Mid-day
Afternoon
Evening
Program ends at 1pm, suggested return flights are after 4pm on Friday, June 7th
If available, include their seat preference (please remember that their preference might not be available)
*
Please Select
Aisle
Middle
Window
If they have a flight that they would like to book please add the link below, we will do our best to accommodate (please also add airline[s] and frequent flyer ID/account number[s] if they want us to register that information when booking).
Please verify that you are human
*
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