Participant Registration 2018 ABCs Participant InformationIn order to get the most accurate information possible, we ask that each individual fill out their own registration form, regardless of who is paying the registration fee. If you are a staff member hoping to reserve space for your students, you may do that by completing payment and having each student register at a later date. Name* First Last Preferred NameThis will be used for conference materials, including name tags. Please write your name exactly as it should appear.School or Organization*Program NamePosition Within Your Program*Preferred Email*Follow-up information will be sent electronically, so please provide an email address you will be checking frequently. Personal Email*Please provide an email address not attached to your college or university. Phone*Mobile, not office - we'll only call if we absolutely need to!Facebook NameWe'll add you to the official conference Facebook group!T-Shirt Size*---SmallMediumLargeX-LargeXX-LargeConference InformationWe ask that no more than four participants from the same school or organization attend the same ABCs session to allow for a diversity of institutions present at each conference.Which week would you like to attend?*June 3 - 8, 2018 | Placemaking & Public Art in Evolving Spaces | Atlanta, Georgia (FULL)June 17 - 22, 2018 | The Hands that Rebuild: Workers’ Rights in the Wake of Disaster | Houston, Texas (FULL)July 8 - 13, 2018 | The Shifting Principles and Practices of Housing Policy | Salt Lake City, Utah (FULL)July 22 - 27, 2018 | America’s Best Idea: Common Ground in Uncommon Spaces | Prince William Forest Park, VirginiaABCs & STAFF TRACK | June 3 - 8, 2018 - Placemaking & Public Art in Evolving Spaces | Atlanta, GeorgiaSTAFF TRACK ONLY | June 6 - 8, 2018 | Atlanta, GeorgiaEmergency InformationIn case of emergency, contact:Name* First Last Relation*Phone*Alternate PhoneInsurance InformationDo you have your own medical insurance?*YesNoInsurance CompanyPlan NameAccount / Policy #Expiration Date Other InformationDate of Birth Year of GraduationIf not applicable, leave blank.Gender Identity (i.e. Woman, Non-Binary, Trans*, Man, Genderqueer)This information will be used for housing purposes only. Racial/Ethnic Identity (i.e. Black, Asian, Latinx, Native, Multiracial, White, etc.)It's important to have a strong understanding of our own identity and positionality when entering communities that aren't our own. This information will be used to build teams that represent the range of our conference community.Please list any health-related issues or dietary restrictions (food preferences/allergies) we should know about. Break Away strives to offer training that responds to the needs and talents of its participants. Please list anything we should know to create a space for you to participate fully. Agree to TermsRegistration is not finalized until payment is received.*I'm all set; we've already paid!I haven't paid yet but will soon.I'm an Advantage chapter and would like to use my one free registration.Cancellation/Refund Information*Partial refunds, subject to a minimum $100 cancellation fee, will be allowed for participants whose cancellation is received in writing at least one month in advance of the session they registered for. No refunds will be given for cancellations made within three weeks of the session. I understand and agree to Break Away's cancellation/refund policy Full Participation Agreement*I have read the ABCs cancellation policy and agree to its terms. I also understand that the ABCs are completely alcohol and other drug-free. If I am found to consume these substances anytime during the official ABCs week, I will be asked to leave without reimbursement. Furthermore, I understand that I am part of an alternative break experience that requires me to remain on location with the group for the entire week. If I want to explore the city on my own, I will make arrangements to do so before the session begins or after it ends. Finally, I understand that at least 12 hours of the training will include direct service projects in the local community. I affirm that I am willing and able to participate in these projects, some of which may require physical labor. I agree to notify Break Away if I have an illness or disability that will prevent me from engaging in strenuous physical activity or certain types of projects so that alternate arrangements can be arranged in advance. I also understand that I will be expected to participate in all scheduled activities - including workshops, service projects, reflection sessions, and other activities. I know all of this and I'm thrilled to attend! I have read and agree with the Full Participation Agreement Signature We look forward to seeing you this summer! In the weeks leading up to the ABCs, you will receive comprehensive information on your particular ABCs through a conference listserv, facebook page, and pre-packet. *Please note that your registration is not complete until payment or proof of payment has been received.