2023 Workshop: April 12-14, 2023 Registration is now open. For more information, please visit the Workshop section of the website. 2023 Registration Race (for statistical purposes) American Indian or Alaskan Native Asian Black or African American Hispanic or Latino Native Hawaiian White Prefer not to answer Age Range (for statistical purposes) 15-24 25-34 35-44 45-54 55-64 65 and over Prefer not to answer Prefix Ms. Mrs. Mr. Dr. Judge Mayor Name First Last Last Gender (Used for room assignments.) Male Female Email Professional Title/Occupation Organization Address Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal County Work Phone Cell Phone Phone Number in case of emergency Dietary Restrictions or Special Needs Required (we will attempt to accommodate requests) Name you desire on your NAME TAG Room Choice Double Occupancy $325 (You will be Assigned a roommate!) Single Occupancy $375 (NOTE: Single rooms are limited and filled on a first-come/first served basis) Scholarship (Double Occupancy) You must note who is providing scholarship below. Scholarship (Single Occupancy) $50 supplement Roommate choice, if known. Otherwise, we'll assign a roommate to you. Spouse/guest meals ($60) Yes ($60) If you have a scholarship, please choose the "I'll mail in a check" option below. How Would You Like to Pay? (if you are paying for a supplemental charge--private room--do not select "I have a scholarship" By Credit Card (see below) I'll Mail in a Check I have a scholarship Scholarship Provided by * Total to be charged Please mail your check made out to Your Town Alabama to the following address:Your Town Alabama 2112 11th Ave S, Suite 541 Birmingham, AL 35205 Credit Card All refund requests will be subject to a $150 fee; the remainder of the fee will be refunded if cancelled 30 days prior to the workshop. No refunds will be issued within 30 days of the workshop. Registrations may be transferred to another person at no cost if a completed application is received 30 days prior to the workshop. Please email us at info@yourtownalabama.org with any questions, cancellations, and transfer requests. Optional Message If you are human, leave this field blank. Pay Now
