DELEGATE INFORMATION
Name
*
First Name
Last Name
Preferred Name (As it will appear on name tag)
*
Gender (please specify)
*
Pronouns
*
Email Address
*
example@example.com
Host Institution
*
Arkansas State University
Arkansas State University - Beebee
Arkansas Tech University
Baylor University
Blinn College
Centenary College of Louisiana
East Central Oklahoma University
Howard College
Lamar University
Louisiana State University
Loyola University
Midwestern State University
Nicholls State University
Northeastern State University
Oklahoma State University
Regional Board of Directors/Special Guest
Sam Houston State University
Southeastern Louisiana University
Southeastern Oklahoma University
Southern Arkansas University
Southern Methodist University
St. Mary's University
Stephen F. Austin State University
Tarleton State University
Texas A&M University
Texas A&M University - Commerce
Texas A&M University - Galveston
Texas A&M Univertiy - Texarkana
Texas Christian University
Texas State University
Texas Tech University
Texas Woman's University
Tulane University
Tulane University
Tyler Junior College
University of Arkansas
University of Arkansas - Fort Smith
University of Arkansas - Little Rock
University of Central Arkansas
University of Central Oklahoma
University of Houston
University of Louisiana - Lafayette
University of North Texas
University of Oklahoma
University of Texas - El Paso
University of Texas - San Antonio
University of Texas - Pan American
University of Texas at Austin
University of Texas at Dallas
University of Tulsa
West Texas A&M University
Other
If you selected "Other" for your institution, please put your institution below. If you selected an institution above, please skip this question.
Would you like to be considered for gender neutral housing?
*
Yes
No
Delegate information: (please check all that apply)
*
First Time Delegate
Returning Delegate
Advisor
NCC
NCC- IT
NRHH Representative
NRHH- IT
RHA President
RHA President- IT
RBD
Are you submitting a program?
*
Yes
No
T-Shirt Size (please check one)
*
X-Small
Small
Medium
Large
X-Large
XX-Large
XXX-Large
Dietary Needs
*
Kosher
Dairy Free
Gluten Free
Vegan
Vegetarian
None
Other
Would you like to opt into gender neutral housing?
Yes
No
Special Needs- Do you have any special needs during the conference (i.e. accessibility, housing, etc.)? If yes, please specify.
*
Medical Needs- Do you have any special medical needs during the conference? If yes, please specify.
*
What is your favorite childhood memory? Ex.) favorite tv show/why, something strange you did/weird habits you had, this could really be anything you loved/hated/find interesting from your childhood! get creative, we will be displaying these at conference!
*
Emergency Contact
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship
*
Insurance Information
*If none, please type N/A in each box*
Provider
*
Policy Number
*
Providers Phone Number
*
-
Area Code
Phone Number
Submit
Should be Empty: