Grassroots Network

Your Registration Info

Organisation (employer) *

First Name *

Last Name *

Email Address *

Street Address

Phone number *

Your Preferred Pronouns

Please indicate if you consent for photos and videos to be taken of you at the event and shared in marketing materials *

Yes

No

Let us know how we can make the event more accessible or comfortable for you. Please include details if you require support to evacuate the venue in the event of an emergency. Leave blank if not applicable.

Accessibility Needs

Let us know if you have any specific dietary requirements. Leave blank if not applicable.

Dietary requirements