Non-member Event/Workshop Registration Form
This form is ONLY for people who do not reside within PHRA that want to register for a PHRA event/workshop. Please note that most PHRA events and workshops are for members only. Only some events/workshops are open to non-members. If an event or workshop allows non-member participation, you may complete this form to register. Submitting this form does not confirm your registration. Our team will follow up with you within 2 business days to confirm. If payment is required, we will contact you to complete payment over the phone and registration will only be confirmed when the payment is received.
Title of the event/workshop you wish to register for
*
Participant Name
*
First Name
Last Name
Participant Date of Birth
*
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Month
-
Day
Year
Date
Current Date
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Month
-
Day
Year
Date
AGE
Participant Phone Number (if under 18, please use parent or guardian number)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Participant Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorized Pickup Name
*
First Name
Last Name
Emergency Contact 1
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact 2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Medical notes
Submit
Should be Empty: