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Birth Justice Days at the Capitol Registration Form
This is the registration form for those traveling to Tallahassee, Florida for Birth Justice Days at the Capitol.
April 14-16, 2025
Thank you for completing as soon as possible. Spaces are limited and will be on a first come first serve bases.
* Indicates required question
Email
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Your email
Last Name
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Your answer
First Name
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Your answer
Pronouns
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Your answer
Organization
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Your answer
Residential Address
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Your answer
Phone Number (including Area Code)
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Your answer
Do we have your permission to text you?
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Yes
No
Location (City/County/Zip Code)
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Your answer
Will you be traveling with minors (18 years or under)?
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Yes
No
Undecided
If Yes, please share their ages.
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Your answer
Will you need transportation to Tallahassee?
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Yes
No
Undecided
Will you need lodging in Tallahassee?
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Yes
No
Undecided
Are you willing to drive to Tallahassee?
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Yes
No
Maybe
Are you willing to transport others to Tallahassee?
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Yes
No
Maybe
If Yes, How many seats will be available?
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Your answer
Emergency Contact (Name)
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Your answer
Emergency Contact (Phone number)
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Your answer
Dietary Restrictions
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Vegetarian
Vegan
Gluten-free
Pescatarian
None
Pickup and Drop off
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Miami-Dade County
Broward County
Palm Beach County
Orange County
Alachua County
Own travel arrangements
Social Media Handles and/or Website link
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Your answer
How did you hear about SBJN?
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Your answer
I am a... (Select all that apply)
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Pregnant Person
Parent
Partner
Midwife
Other Medical Provider
Doula
Other birth worker
College student
HIgh school student
Community organizer
Business owner
Reporter/Journalist
Other
Required
If other to above question (please specify)
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Your answer
Do you have experience speaking with legislators?
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Yes
No
Do you feel comfortable talking to folks about birth justice?
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Yes
No
What are you hoping to gain from this experience?
Your answer
Check all the boxes below to ensure you are willing to honor our values / agreements:
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Stand Against Racism / Being Anti-Racist
Center Black, Brown, youth, immigrant, Indigenous, LGBTQ+, low-income, and other marginalized communities.
Advocate for Birth Justice and Human Rights
Ensure Access to Full Spectrum Pregnancy Care and Birth Options
Respect Boundaries of Self & Others with Compassion and Accountability
Honor Bodily Autonomy and Self-Determination
Required
If you have any comments questions or concerns, please leave them here
*
Your answer
Send me a copy of my responses.
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