2018 Sacrament Safari Registration Sacramento Safari Registration Form 2018 Please fill in all text fields marked with an * , then click "submit". Name* First Last Name will appear this way on nametagGender* Male Female Email* Cell Phone*Home Phone*Mailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Room Selection*Single Occupancy - $475Double Occupancy - $360Roommate name, if you selected double occupancy First Last (If listing a roommate, confirm their availability first. A roommate will be assigned to you if you do not request one.) Meals Vegetarian Gluten-free Special Dietary Issues First Time Attendee?*YesNoPTA CouncilChoose oneAnaheim ElementaryAnaheim SecondaryBreaBuena ParkCapistranoCypressEl Dorado O'EsteFullertonGarden GroveHarborHuntington UnionIrvineLa HabraLaguna BeachLos AlamitosOrange CommunityOut of CouncilPlacentia-Yorba LindaSaddleback ValleySanta AnaWestminsterFourth District PTAOtherName of the PTA that voted to appoint you*Name of your PTA President*PTA President's email address*Your current PTA position?Your Assembly Member's District #* 55 PHILLIP CHEN 65 SHARON QUIRK-SILVA 68 STEVEN S. CHOI 69 TOM DALY 72 TRAVIS ALLEN 73 WILLIAM P. BROUGH 74 MATTHEW HARPER OTHER You may select more than one. Your State Senator's District #* 29 JOSH NEWMAN 32 TONY MENDOZA 34 JANET NGUYEN 36 PATRICIA C. BATES 37 JOHN MOORLACH OTHER You may select more than one.List any legislators from Orange County that you personally know Not sure of your legislators? Click on this link to find out… http://findyourrep.legislature.ca.gov/Total $0.00 Emergency Contact InformationName*Relationship*Cell Phone*Work PhoneHome phone*Health InformationAny health-related information we should be aware of? Date* If you are paying by check, funds are due to the Fourth District PTA office within two weeks.