Membership Summit Request Form – ACWA JPIA

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Search for:

ABOUT US
BENEFITS
REPORT A CLAIM
- Liability & Property
- Workers’ Compensation
SERVICES
PROGRAMS
RISK CONTROL
TRAINING
NEWS
PODCASTS
CONNECT
CAREERS

ABOUT US
BENEFITS
REPORT A CLAIM
- Liability & Property
- Workers’ Compensation
SERVICES
PROGRAMS
RISK CONTROL
TRAINING
NEWS
PODCASTS
CONNECT
CAREERS

Membership Summit Request FormLaura Baryak2026-08-25T08:56:02-07:00

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2026 JPIA Fall Membership Summit

1. Attendee Information

Name *

First

Last

Title *

If other, please Specify:

Email *

Phone *

Please use the phone number associated with the participant attending the Membership Summit (cell phone).

Address *

Address Line 1

City

State

Zip Code

2026 Fall Membership Summit

2. Member Information

Member Agency Representation (or Non-Member) *

Member Agency

Member Agency

Member Agency

Name of non-JPIA member Agency that you represent

Are you the designated ACWA JPIA voting representative for your member agency? *

Yes
No

FPPC Form 700 Compliance (Required for Voting Members) *

I acknowledge that I am the designated JPIA Director or Alternate Director for my agency. I further acknowledge that JPIA Directors are required to have a current FPPC Statement of Economic Interests (Form 700) on file in order to serve and vote in good standing on the ACWA JPIA Board, and that I will submit this form to ACWA JPIA if it is not current.

2026 Fall JPIA Membership Summit

3. Event Participation

Monday, November 30 Lunch. Kindly RSVP to confirm your attendance. *

Yes, attending lunch
No

Monday evening Reception RSVP *

Yes, I plan to attend
No, I have other evening plans

2026 JPIA Fall Membership Summit

4. Accommodations & Dietary Needs

Do you have any dietary restrictions or food allergies? *

None
Vegetarian
Vegan
Gluten-Free
Other (please specify)

Other: Dieatary restrcitions or food allergies

Do you require any reasonable accommodations to participate in JPIA meetings? If so, please specify.

2026 JPIA Fall Membership Summit

5. Additional Information

Emergency Contact

Emergency Contact Name *

First

Last

Relationship *

Phone *

Is this your First ACWA JPIA Membership Summit? *

Registration Acknowledgment *

I understand that summit materials will be available approximately two weeks prior to the event through the ACWA JPIA website.

Message

Follow @ACWAJPIA

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