12th Annual Latino Health Equity Conference - Registration

12th Annual Latino Health Equity Conference Registration

Please complete this form to register for the 12th Annual Latino Health Equity Conference on June 24-25, 2021.
* If you are registering a group a of 6 or more attendees, before you complete this form, please contact team@raiseagent.com to receive a group discount code prior to registering here.

First Name : *

Last Name : *

Email: *

Mobile Number: *

Organization: *

Job Title: *

Address : *

City : *

State: *

Zip Code : *

I am interested in CEC/CEUs from this event: *

School Name:

Program :

Languages Spoken : *

English

Spanish

Other

How do you identify ( race/ ethnicity, other): *

Gender identity: *

What is your age range? : *

How did you hear about this event? :

Add me to Familias en Acción email list:

Select your ticket. Once you complete the registration process, you will be redirected to PayPal's secure payment page for fee-based tickets:

	Required Ticket* You must select one ticket from this section before continuing.	Price
	Individual Registration	$129.00
	Student Registration	$65.00

Total: 0

* required