Participant Information Please submit a separate form for each individual (photocopies are acceptable). Note: Name tags will be produced from the information printed below (PLEASE TYPE OR PRINT CLEARLY.) Full Name E-mail Title Agency/Affiliation/Community Address City State Zip/Postal Code Telephone Fax Race/Ethnicity: African American Asian Pacific Islander Caucasian Latino/a Native American/Alaska Native Other Gender: Male Female Transgendered Age: Under 18 19-25 26-33 34-40 41-Older Selection Criteria Each applicant interested in attending will be required to participate in some aspect to assist with facilitating the institute. Please select from the options below to indicate the area in which you will serve. Facilitating a workshop or roundtble discussion (Please include with application an outline of your workshop or roundtable that includes topic description, issues to be discussed, learning objectives, and solutions, methods, models or examples.) Assisting with facilitating the institute which includes helping with registration, serving as runners, monitors for workshops, and serving as host at food functions.
All Applicants MUST submit a resume to afox@murc.org along with application.
