CICA Member Registration

First Name of Registrant Last Name of Registrant Preferred Pronouns (Examples: She/Her, He/Him, They/Them) Email of Registrant Day Phone of Registrant Home Mobile Other Work Address Address Line 3 Address Line 4 City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix CSUCI Media Consent & Release (CSUCI MCR) YES - I have read and accept the CSUCI MCR. This serves as my electronic signature. NO - I have read and do not accept the CSUCI MCR. This serves as my electronic signature. CICA Media Consent & Release (CICA MCR) YES - I have read and accept the CICA MCR. This serves as my electronic signature. NO - I have read and do not accept the CICA MCR. This serves as my electronic signature. CICA Volunteer Waiver, Release and Indemnity Agreement (VWRI) Yes. I have read the VWRI Agreement and accept its terms for all persons for whom I am executing this registration. This serves as my electronic signature. No. I have read the VWRI Agreement and DO NOT accept its terms. This serves as my electronic signature. Syllabus Yes. I have read the Syllabus. I accept the terms and this serves as my electronic signature No. I have not read the Syllabus. I do not accept the terms and this serves as my electronic signature If you replied NO to any of the required fields, you are invited to add your comments or questions. A representative from CICA will follow up with you as soon as possible. Volunteer Interest. Check all that apply.