Ending Dating Violence: How to be the Generation of Change

Free Registration

To register for the symposium on Thursday, November 19 - please answer the questions below.

The event will be held at the Jewish Community Center of Greater Pittsburgh from 5PM-7PM.

Registration table opens and food begins at 4:00PM.

**Separate contact information must be filled out for each additional youth**

Please contact Kristen Herman (kherman@pcadv.org) with any questions. More information can be found at www.pcadv.org/Get-Involved/Special-Events/

Question Title

* 1. Adult Contact Information (adult accompanying below youth)

Name

Title

Organization

Email Address

Phone Number

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* 2. Youth Contact Information

Name *

School *

Grade

Age

Email Address *

Phone Number *

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* 3. Youth Contact Information (2)

Name

School

Grade

Age

Email Address

Phone Number

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* 4. Youth Contact Information (3)

Name

School

Grade

Age

Email Address

Phone Number

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* 5. Youth Contact Information (4)

Name

School

Grade

Age

Email Address

Phone Number

Question Title

* 6. Youth Contact Information (5)

Name

School

Grade

Age

Email Address

Phone Number

Ending Dating Violence: How to be the Generation of Change

Free Registration

Question Title

* 1. Adult Contact Information (adult accompanying below youth)

Question Title

* 2. Youth Contact Information

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* 3. Youth Contact Information (2)

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* 4. Youth Contact Information (3)

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* 5. Youth Contact Information (4)

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* 6. Youth Contact Information (5)

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* 7. Any Dietary Restrictions? Please list for each individual person. (i.e. vegetarian, kosher, food allergies, etc.)

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* 8. Please list any accessibility needs or alternate accommodations needed.

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* 9. Other Comments: