The Kopanya Institute - Of Skin, Soul, and Soil - Registration Form Survey

Thank you for your interest in Kopanya's upcoming journey "Of Skin, Soul, and Soil: A Healing Space for People of Colour"!

Due to unforeseen circumstances, we've had to postpone the start date to early 2021. Please continue to fill in this form as an expression of interest, and then we will be in touch in the new year with rescheduled dates.

All the information you provide here will be kept confidential and will not be shared with anyone without your permission.

Please contact us at kopanya.courses@gmail.com with any further queries, or to set up an informal hello!

1.Please provide us with your personal details:

First Name (preferred name):

Surname:

Location (where do you live):

Date of birth:

Profession or area of study:

2.What sparked your interest to join this course?

3.Name one area or aspect of your life in which you have been challenged in exploring race and racism, recently or longer term:

4.Name one area or aspect of your life in which you have found empowerment, hope, or liberation around race and racism:

5.What would your hopes be for this journey as a whole? Is there anything specific you would like for us to explore?

6.Do you identify as a Person of Colour?

Yes

Other (please specify)

7.Is there anything else you would like for us to know?

8.Where did you hear about this course?

9.Please provide us with your contact information:

Email address:

Cell phone number:

Do you have WhatsApp? (and is it the same as your cell # above?)

Facebook username (if you are on Facebook):