2018 Conference Registration Name* First Last Title*Agency*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Phone*Adult or Youth*AdultYouth (for 12 years & older please list age)Youth Age*I am attending*June 27, 2018 Certified TMEC Instructor Workshop 6 – 9pm FREEJune 28-29 ConferenceBoth Workshop and ConferenceAre you applying for a scholarship?*NoYesNo payment will be processed at this time if "Yes" is selected.How much are you requesting in scholarship money?*Meals* All Meals None Do you have any dietary restrictions? If so, please list.*NoYesDietary restrictionsJune 28-29 Exhibitor Booth*NoYesPlease mark if you want to have an exhibitor booth at the conference. If yes, list the name of the organization showcased. There is a $200 cost for an Exhibitor booth.Name of organization*Do you need Spanish translation?*NoYesDo you need any other accommodations?*NoYesDescribe your needed accommodations*How did you hear about the conference?Are you are interested in bringing a prize for us to raffle off or use in silent auction at the conference?*YesNoMaybePrizes valued under $50 will be used in the raffle. Prizes valued over $50 will be used in the silent auction at the conference.Prize estimated at*Under $50Over $50Unknown All donations and proceeds go to CLEAR Alliance for youth substance use and impaired driving prevention education.Free “Quick-Click” Seatbelt Challenge*Yes, I do want to participate in the Quick Click seat belt challengeNo, I do not want to participateI will be paying by:*Credit CardCheckTotal $0.00 EmailThis field is for validation purposes and should be left unchanged.