Grace Project Conference Out-Of-Town Registration

Primary Language

I will need English translation:*

Yes
No

Registrant Information

Name*

First Last

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Alternate Phone

May we discreetly call you and/or leave messages on your home or cell phone?*

Yes
No

Emergency Contact Name*

First Last

Emergency Contact Phone*

Select Your T-Shirt Size*

Did you attend the 2022 Conference?*

Yes
No

Hotel Information

PLEASE NOTE: To lower the risk of COVID exposure and transmission, conference participants have the option of requesting a roommate who has received vaccination against COVID-19.
*Conference participants may request a single room (no roommate) at the reduced rate of $109 per night.
Book your single room for the Grace Project Conference HERE. The deadline to book a single room is May 4, 2023.

Choose a hotel option*

I will share a hotel room. Please match me with a roommate.
I would like to share a hotel room with the person indicated below.
I would like a single room. (if you select a single room, a room will not be reserved for you. You will need to book and pay for your own room using the link provided above)

I prefer a roommate who has received the COVID vaccine*

Yes
No
Don't care

I would like to share my room with:*

Enter the first and last name of your preferred roommate

The person named above has already agreed to be my roommate

Yes
No

Registration Payment*

I would like to apply for a scholarship
I will pay the $50 conference fee

Limited Scholarships*

I understand that scholarships are limited, and this option does not guarantee me a spot at the conference. Legacy Counseling Center will contact me to gather additional information in consideration for a scholarship and will maintain a waitlist should additional scholarships become available.

I understand that scholarships are limited

I will make payment*

when I submit my registration
by mail to Legacy Cares, 4054 McKinney Ave Suite 102, Dallas, TX 75204
over the phone by calling 214-520-6308 ext 384

Have you attended the Grace Project Conference in the past?*

Yes
No

How many Grace Project Conferences have you attended?*

Please enter a number from 1 to 10.

Why are you interested in attending the conference?*

What does the Grace Project Conference mean to you and what do you hope to gain from the experience?*

Would you be able to attend if you are not granted a scholarship?*

Yes
No

If you are able to attend the Grace Project, will you commit to attending the workshops to gain knowledge?*

Yes
No

Conference Attendee HIV Status Acknowledgement*

I recognize this conference is designed only for women living with HIV. For confidentiality reasons, I understand that I may not invite friends, family, or others who have not been diagnosed with HIV. I also acknowledge that I will need to provide proof of diagnosis either before the conference or at registration.

I understand

Hidden

Conference Attendee HIV Status Acknowledgement*

I understand

I recognize this conference is designed only for women living with HIV. For confidentiality reasons, I understand that I may not invite friends, family, or others who have not been diagnosed with HIV. I also acknowledge that I will need to provide proof of diagnosis either before the conference or at registration.

I have received the COVID vaccine*

Yes
No

Which COVID vaccination did you receive?

Pfizer
Moderna
Johnson & Johnson

Please list the dates of all COVID vaccination doses and boosters, if applicable

Date of first vaccination dose

Date of second vaccination dose

Date of first booster (if applicable)

Date of second booster (if applicable)