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Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Location

Not needed

Street Address Line 2

CityState / Province

Sobriety Date

Date

Accommodations?

If yes, please describe:

Willing to be of service?

NHSCYPAA XXVII registration

Entrance to NHSCYPAA XXVII

$20.00 Quantity

Scholarship

Covers the cost of conference attendance for an alcoholic in need

$20.00 Quantity

Donation

Donated funds regardless of conference attendance

$5.00 Quantity

Donation

Donated funds regardless of conference attendance

$10.00 Quantity

Donation

Donated funds regardless of conference attendance

$25.00 Quantity

Total

Credit Card

Apple Pay

Cash App Pay

Pre-Register