Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
State
*
Sobriety Date (mm/dd/yyyy)
*
Home Group/Service Committee
*
Handicap Accessibility
*
Yes
No
If Yes, please specify:
Interpretation Needed?
*
Yes
No
If Yes, please specify:
Willing to be of service?
*
Yes
No
Notes:
Payment
prev
next
( X )
NHSCYPAA XXVI Registration
$
30.00
Scholarship
$
5.00
Scholarship
$
10.00
Scholarship
$
15.00
Scholarship
$
20.00
Scholarship
$
25.00
Scholarship
$
30.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Submit
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