TRAVEL GROUP REGISTRATIO FORM

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BMCC ROOM/RIDE SHARE LIST/GROUP APPLICATION

Due to safety and confidentiality concerns, we make every effort to screen for inclusion in the list and online group.

I will email you when I receive your completed form and add you to our list of attendees looking for ride/room shares.

If at all possible, I will try to match travel and roommates up using the list rather than opening up the Google group.

Thank you for helping us in our efforts to keep everyone safe!

Sincerely,

Liliane Miller, Vice Chair, BMCC

1. LAST NAME

2. FIRST NAME

3. EMAIL

4. PHONE NUMBERS BEFORE/DURING THE CONFERENCE

5. I AM A

Mom DV Advocate Other

SHARING RIDE/TRAVEL COSTS

6. I AM COMING TO THE CONFERENCE FROM (CITY AND STATE)

7. I AM LOOKING FOR

I am driving and looking for riders I am looking for a ride I can either drive or be a rider

8. DATE AND TIME I PLAN TO SET OUT FOR THE CONFERENCE

8. DATE AND TIME I PLAN TO LEAVE THE CONFERENCE

SHARING LODGING COSTS

9. I AM LOOKING FOR A ROOMMATE/S FOR

Thursday night Friday night Saturday night

10. I AM WILLING TO SHARE A ROOM WITH

1 others 2 others 3 others

11. SMOKING/NON SMOKING

I am a smoker I am willing to share a room with a smoker I cannot be around cigrette smoke

12. LIST ANY SPECIAL NEEDS/SITUATIONS (ALLERGIES, ETC.)

13. I AM ALREADY REGISTERED TO ATTEND THE CONFERENCE.

YES NO

ADDRESS CITY/COUNTY/STATE

NAME/S CONTACT INFO OF ANYONE YOU KNOW WHO IS AFFILIATED WITH BMCC, INCLUDING ATTENDEES PAST AND PRESENT.

NAME/S AND CONTACT NUMBERS OF ANY DV ADVOCATES/AGENCIES YOU HAVE WORKED WITH.

IF YOU ARE AN ADVOCATE, WHAT IS THE NAME, CONTACT INFO, AND LOCATION OF YOUR AGENCY AND YOUR ROLE?

COURT CASE IS IN CITY/COUNTY/STATE

NAME OF CASE

CASE NUMBER

CASE DATE

AGE AND SEX OF CHILDREN AT COMMENCEMENT OF CASE

JUDGE/S

YOUR ATTORNEY/S

OPPOSING ATTORNEY/S

CUSTODY EVALUATOR/S

GAL/MINOR’S COUNSEL

PARENT COORDINATOR/S

THERAPIST/S

OTHER COURT PLAYERS

HOW MUCH DID YOUR CASE COST?

OUTCOME OF YOUR CASE AND ANY OTHER INFORMATION YOU WOULD LIKE TO SHARE WITH US.