Montana Gay Men's Task Force

Montana LGBTI Summit: Working Towards Healthcare Equality
October 13, 2007
(Confidentiality Ensured)

You MUST be 18 years or older to register for this Summit.

Please complete the following electronic registration form as thoroughly as possible. Make sure you hit the "submit registration" button at the bottom of the electronic registration form. DO NOT HIT ENTER. INSTEAD TAB OR CLICK TRHOUGH THE FIELDS (Hitting enter will submit your registration form prematurely). You will be contacted shortly (within 2 - 3 business days to confirm your registration. Registration deadline is October 1st.

Registration cost $25 ($35 if receiving Continuing Education Credits) and should be included with your application to help cover expenses at the Summit including a continental breakfast and lunch. Registration must be either check or money order and made out to FDH & Associates. A limited number of scholarships are available (especially for students and those living lightly!). Please contact FDH if you are interested.

NEW Student Rate! Students that want to attend the summit can pay a $10 registration fee. However scholarships can also be available for students that can't pay anything. Please inquire with FDH.

Please send your registration payment to:
FDH & Associates
P.O. Box 7984
Missoula, MT 5980

If you have any questions regarding this registration or about the Montana LGBTI Summit, please call 406.829.8075 or email: fdh@mtgayhealth.org

Do you live in Montana? Yes No

Have you been to a FDH or GMTF sponsored retreat in the last 12 months? Yes No

First Name: Last Name:

Organization: Occupation:

Postal Address (include apt #):

City: State: Zip Code:

Telephone: Email Address:

Lunch will be provided. Do you plan on staying at the Summit for lunch? Yes No

Do you have any medical or dietary restrictions?
Yes No
If YES, please explain:

Emergency Contact Name: Emergency Contact #:

When will you be arriving at the Summit:
(The Montana LGBTI Summit begins on Saturday, October 13th, at 8:30am and ends at 4:30pm.)

I, the undersigned, understand and agree to release the Montana Gay Men's Task Force, FDH & Associates, their members and officers, designated assistants, other attendees, and affiliated groups and persons, from any and all liability including all degrees of physical and/or mental injury, property damage, loss, or theft that may be incurred as a result of my attendance at the Montana LGBTI Summit. I understand and accept that attendance is purely at my own risk. I agree to the strict no drug or alcohol rule and realize that I may be asked to leave if I violate this policy. I have filled out this form fully and completely to the best of my knowledge.

Please send your registration payment to:
FDH & Associates
P.O. Box 7984
Missoula, MT 59807

Signature (Name in all CAPS): Date (mm/dd/yy):

To cover my cost for lodging and meals, I will be sending a check/money order in the amount of:

Other additional comments:

This site contains HIV prevention messages that may not be appropriate for all audiences.
This site is made possible through funding provided by the Montana Department of Public Health and Human Services (DPHHS), HIV/STD Prevention Section.