STEP 1: Alliance for Biking & Walking 2012 Leadership Retreat Registration Form

Important information to read before registering:
  • Dates to remember: The 2012 Leadership Retreat will take place from September 7 through 10, the weekend before Pro Walk/Pro Bike.
  • The retreat will take place in Long Beach, CA, at the Queen Mary, located at 1126 Queens Highway, Long Beach, CA 90802.
  • The cost of the retreat for Alliance members is $410 US if you register before June 15 and $485 if you register after that date. Registration closes on August 12, after which point anyone wishing to attend the retreat will need to pay an extra $25 to cover additional cost from the hotel. There is an additional cost of $50 for all participants who are not Alliance members. Registration includes lodging and meals. You may bring an additional guest, such as a spouse or partner, for $260, which includes meals and lodging but not participation in the retreat.

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Participant's Contact Information:

First name:
Last name:
Organization:
Email Address:
Phone Number:

Participant's Meals, Lodging, and Other Preferences:

Dietary Requirements: Do you have any requirements regarding refreshments or meals?

No Preference
Vegetarian
Vegan
Other:

Lodging: Lodging at the Queen Mary is provided as part of registration. Two participants will be assigned to each room. Please tell us the names of people that you might want to room with and we will do our best to accomodate your request.
Lodging What days are you planning on staying at The Queen Mary?

Thursday
Friday
Saturday
Sunday

Lodging: Other special requests regarding lodging arrangements?
Be sure to include any special adaptations you need.
Printed Materials: The Alliance may provide printed materials for all participants.
Please indicate if you would like the materials in another format to meet your needs.		 No Adaptation Is Required
Electronic (Word)
Electronic (PDF)
Large Print
Braille
Other
Other Special Requests:

Other:

Pro Walk/Pro Bike: Are you planning to attend Pro Walk/Pro Bike? Yes
No
Not Sure
I am interested in applying for a scholarship to Pro Walk/Pro Bike

Miscellaneous:

Payment: Please indicate how you will be paying for your registration to the retreat? Online (Via Pay Pal/Credit Card/Electronic Check)
Mailing in the Payment
Phone (Via Credit Card)
Another Organization is Paying my Registration
Other Scholarship
Please send an invoice
Scholarships: There are several full and partial scholarships available for this retreat. If you are interested in apply for a scholarship, please send the following information to retreat@peoplepoweredmovement.org:
  • Your name, organization and position
  • Why you would like to attend the retreat
  • What measurable outcomes your organization would be able to achieve with your participation at the retreat