Marketplace of Ideas - MHA Nation Conference Registration

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MHA Nation Conference Registration

Name of Registrant *
Business/School Name *
Address *
City *
State *
Zip Code *
Email Address *
Telephone
Occupation
Are you a student or a teacher/advisor registering a group of students?		If yes, please indicate the grade level of your student(s): Junior High High School College
Number of students you are registering
Please enter the first and last name of everyone you are registering
Comments or Special Needs/ADA requirements
The following information is requested by the Federal Government in order to monitor compliance with applicable Federal Civil Rights laws. You are not required to furnish this information, but are encouraged to do so. The law states that a provider of services may neither discriminate on the basis of this information, nor on whether you choose to furnish it. However, if you choose not to furnish it, under Federal regulations the provider of services is required to note race, ethnicity, and sex on the basis of visual observation or surname. (Teachers: if you wish to do this for your student group, please indicate each box with a number).
Ethnicity
Not Hispanic or Latino
Hispanic or Latino
Race
White
Black or African American
American Indian/Alaskan Native
Asian
Native Hawaiian or Pacific Islander
Sex
Male
Female

FOR MORE INFORMATION, PLEASE CONTACT: Marketplace of Ideas 210 North 4th Street Bismarck, ND 58501 701-663-0150; Toll-Free: 888-384-8410 Fax: 701-663-1032 marketplace3@btinet.net In accordance with Federal law and the U.S. Department of Agriculture's policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. (Not all prohibited bases apply to all programs.) To file a complaint of discrimination, write to: USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call 800-795-3272 (voice) or 202-720-6381 (TDD).