Registration Waiver Request Form: Community-Based Non-Profit Practitioners
Who should complete this form? Only community-based, non-profit practitioners who: 1) have been accepted to present at the conference AND 2) work in Metro Chicago are eligible for a waiver.
PRESENTER INFORMATION
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Place of Employment (Community-based, non-profit organization)
*
County Where You Work
*
Please Select
Cook, IL
DeKalb, IL
DuPage, IL
Grundy, IL
Jasper, IN
Kane, IL
Kendall, IL
Kenosha, WI
Lake, IL
Lake, IN
McHenry, IL
Newton, IN
Porter, IN
Will, IL
Professional Title
*
Organization Web Address
*
Upload evidence of eligibility
*
Browse Files
Drag and drop files here
Choose a file
(e.g. employment letter, redacted pay stub, screenshot of staff listing on website, etc.)
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of
ABOUT YOUR PRESENTATION
Submission ID
*
Title of Presentation
*
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Submit
Should be Empty: