Spina Bifida Association of Greater New England · 2023 Teen Empowerment Weekend Registration

Contact Information

Parent's Name

*

First Name

Last Name

Preferred Pronoun

*

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Email

*

Verify Email

*

Cell Phone

*

Primary Language

*

SB Teen Information

Teen's Name

*

First Name

Last Name

Teen's Birthdate

*

(mm/dd/yyyy)

T-shirt for Teen?

*

T-shirt (adult-unisex) Size Needed

Please specify the size needed

Yearbook Photo Upload

Upload your Yearbook Photo (upload limited to 10 MB)

Yearbook Bio

Yearbook Contact Info to Share

If you want to share additional information for the yearbook like the teen's social media handles or phone number, enter it here.

Dietary Restrictions / Allergies

Does anyone in your party require/have dietary restrictions or allergies? Please describe below.

Dietary Restrictions?

*

Dietary restrictions or allergies?

Interpreter Request

Does anyone in your party require and Interpreter (ASL, Spanish, Portuguese, other)?

Interpreter Needed?

*

Interpreter needs

Please describe your interpreter needs

Additional Accommodations

Accessible Room Needed?

*

Accommodation Requests

Please describe in detail the accommodations you require. For example, roll-in shower, shower chair, etc.

Photo Release

I agree that SBAGNE may use photos of me and/or my minor children from this event for website, email, Annual Report and social media purposes.

Photo Release

*

Yes

No

Liability Waiver Acknowledgement

By checking 'Yes', you acknowledge that you have read and understood the Liability Waiver Document (click link to read).

Acknowledgement

*

I acknowledge that I have read the Liability Waiver

Yes

No

Program Fee

The registration fee is $75 for a family. If you need a waiver, please contact Jean Bertschmann at jbertschmann@SBAGreaterNE.org after submitting this form.

Registration Fee

$75 - Family

$0 - We need to apply for a waiver

2023 Teen Empowerment Weekend Registration

Friday, March 17 - Sunday, March 19, 2023

DoubleTree by Hilton, Nashua NH

Registration Deadline March 1, 2023

Contact Information

SB Teen Information

Dietary Restrictions / Allergies

Interpreter Request

Additional Accommodations

Photo Release

Program Fee