Program Registration

Number of Attendees: First Name: Last Name: Address: City: State/Province: Alabama Alaska Arizona Arkansas 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 American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip Code: - Zip Suffix Cell Phone: Email: Disability Acquired Brain Injury Blind or Low Vision Cerebral Palsy/TBI Deaf or Hard-of-Hearing Dwarfism or Short Stature Mobility Impairment and/or Limbloss/Deficiency (SCI, Spina Bifida, Transverse Myelitis, Amputation, Burns, Joint Injury) Neuromuscular (CP, Hemiplegia, MS, Muscular Dystrophy, Nerve Damage, Polio, PTS, Stroke) Other I do not identify as having a disability Disability Sub-Type Amputation Burns Cerebral Palsy Hemiplegia Joint Injury Multiple Sclerosis Muscular Dystrophy Nerve Damage Polio PTSD Spina Bifida Spinal Cord Injury Stroke Transverse Myelitis Other I do not have a disability My disability is due to: Cancer Injury Congenital Other I do not have a disability Birthdate Gender: Female Male Non Conforming Ethnicity (check all that apply) Military Veteran? YES - Pre 9/11 Era Yes Post 9/11 Era No T-shirt Size YS YM YL Small Medium Large XL 2XL 3XL Have you completed the electronic waiver and media release? The link below will take you to a new window. Please complete the required signature fields for two waivers and then return to this screen to answer this question REQUIRED: Please click on the following link to agree to GLASA's online waiver and media release BEFORE you check below: Move United Waiver and Media Agreement This is only required once per calendar year. If you have a coupon, please enter code here (case-sensitive):