2023 Rising Tide Dinner
Register
First Name
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Last Name
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Email Address
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Please use this format (207) 555-5555 (there is a space after the closed parenthesis).
Phone
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Cell Phone (if different)
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- select State/Province -
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Pronouns
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He / Him
They / Them
Do you identify as transgender, nonbinary, intersex, or otherwise gender non-conforming?
- select Do you identify as transgender, nonbinary, intersex, or otherwise gender non-conforming? -
Yes
No
How would you describe your gender identity (please select all that apply)?
Male/Man
Female/Woman
Nonbinary
Intersex
Gender queer
Gender fluid
Agender
Other
Do you identify as, or consider yourself part of the LGBTQ+ community?
- select Do you identify as, or consider yourself part of the LGBTQ+ community? -
Yes
No
I identify my ethnicity as:
African American
Asian
Latine/o/a
Middle Eastern
Multiracial
Native American
White
African
Select all that apply
Any accessibility requirements / accommodations?
Do you need interpretation? If so, what language?
suggested donation
This event is free and open to the public. There is a suggested donation of $40 per ticket, but contributions at every level are appreciated!
optional amount
$1.00
Total
Payment Options
Payment Method
Credit Card
Paypal MPA
I will send payment by check
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