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***REGISTRATION IS CLOSED.  ANY REGISTRATIONS RECEIVED AFTER DECEMBER 19TH WILL ONLY BE PROCESSED IF SPACE IS AVAILABLE.***

 If you have any issues using this form, please download and fill out one of the alternate forms listed on the side bar.  Those can be faxed to 540.372.1150, or emailed directly to youthfirst@officeonyouth.org.

**All fields are required unless noted**

Organization Name:     
Address:     
Address 2/Suite #: City:      State:      Zip:     
Phone:      Fax:
Website (optional):

Please select the registration type below. All registered vendors will receive a continental breakfast and lunch for the number of staff members listed below, based on your selection. NO outside food is permitted at the event! All tables are 6’ in length. Space will be allotted and assigned by event staff. Vendors are able to attend all sessions, but will be required to have a staff member present at their assigned table during the lunch break.

Tier 1: Planning District 16 Non-profit vendors only - $75.00 – full table, 2 staff members
     (Tier 1 Vendors MUST have an office based in Planning District 16)
Tier 2: For profit & Outside area non-profits - $275.00 – full table, 2 staff members
Tier 3: Premier vendors - $550.00 – full table, 2 staff members
     (Premiere Vendors will receive priority space, with names & logos in published materials)

Once your registration is submitted, you will receive a confirmation to the email listed below. Payment details will be included. Please do not send payment prior to confirmation.

Please list the names of those staff members representing your organization, and if they would like to attend the afternoon breakout sessions:
Staff 1:   Email Address: 
Lunch Preference: Vegetarian Non-vegetarian
Session Preference: Attachment Disorders Mental Health Awareness/Suicide Prevention Programs

Staff 2: Email Address:
Lunch Preference: Vegetarian Non-vegetarian
Session Preference: Attachment Disorders Mental Health Awareness/Suicide Prevention Programs

Electrical outlets are limited; will your display require electricity? Yes No

Will your agency provide a door prize/raffle item for participants? Yes No

Please list any special accommodations that may be necessary:

Each participant will receive a resource guide listing the name, contact information, and a brief description of your organization/business. Please take a moment to fill out the following information to be included in this guide.

Organization Description (describe general mission/activities/service population/etc.):
 
(1000 characters max)

Please check the types of services offered by your agency/organization/business: (check all that apply)
 

My organization/business provides specific/specialized services for youth who are disabled:
No Yes, please give a brief explanation:

My organization/business charges for services we provide: No Yes Varies by Program/Service

Our services are covered by insurance providers: No Yes Varies by Program/Service

Our services are Medicaid eligible services: No Yes Varies by Program/Service

My organization/business is a CSA approved vendor: No Yes

Click 'Submit' ONCE to submit your registration electronically.  You may want to print this page for your records.  You will receive a confirmation by email within 2 business days of submission.  If you do not receive confirmation, please email ben@officeonyouth.org