Demographic Information First Name * Last Name * Job Title Agency Affiliation (if any) Email * Phone * Emergency Phone Race/Ethnicity * African American Asian/Pacific Islander European/Caucasian Hispanic/Latin Native American Another not listed Mutiracial Prefer not to say County * - select County - Albany Allegany Bronx Broome Cattaraugus Cayuga Chautauqua Chemung Chenango Clinton Columbia Cortland Delaware Dutchess Erie Essex Franklin Fulton Genesee Greene Hamilton Herkimer Jefferson Kings Lewis Livingston Madison Monroe Montgomery Nassau New York Niagara Oneida Onondaga Ontario Orange Orleans Oswego Otsego Putnam Queens Rensselaer Richmond Rockland St. Lawrence Saratoga Schenectady Schohaire Schuyler Seneca Steuben Suffolk Sullivan Tioga Tompkins Ulster Warren Washington Wayne Westchester Wyoming Yates Postal Code * If you wish to register multiple attendees please contact, LIFT Executive Director, Andrea Stolz, at astolz@lift4kids.org Event Fee(s) * Professional - $ 30.00 Parent/Caregiver - $ 0.00 Youth - $ 0.00 Policymaker - $ 0.00 Total Payment Options Payment Method Pay Online via Credit Card Pay later option is for individuals who will pay by check ONLY. Credit Card Card Type - select - Visa MasterCard Amex Discover Card Number * Security Code * Expiration Date * -month- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec -year- 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 My billing address is the same as above Billing Name and Address Billing First Name * Billing Middle Name Billing Last Name * Street Address * City * Country * - select - United States State/Province * - select State/Province - Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas United States Minor Outlying Islands Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Postal Code * Review
