Anti-Racism Workshop Registration - September 2015 Question Title * 1. Name Question Title * 2. Phone Number Question Title * 3. Email Address Question Title * 4. Organization/Company/Workplace Question Title * 5. Are you over the age of 18? NO YES Question Title * 6. Race African American/Black Asian/Pacific Islander Latino/a/Hispanic Native/Indigenous White Biracial/Multiracial Question Title * 7. Religious Identification Agnostic Atheist Buddhist Christian Hindu Jew/Jewish Muslim Pagan/Wiccan Sikh Spiritual Self Identify Question Title * 8. Sex/Gender Female Male Transgender Gender Non-Conforming Self Identify Question Title * 9. Sexual Orientation Straight Questioning Bisexual Pansexual Gay Lesbian Queer Self Identify Question Title * 10. Socio-Economic Class Background Family makes $18,000 or less per year Family makes between $19,000 and $34,000 Family makes between $35,000 and $74,000 Family makes between $74,000 and $100,000 Family makes over $100,000 per year Question Title * 11. Disabilities (these can be physical, learning or emotional disabilities) Question Title * 12. Can you commit to attending both full days of training? Thursday, September 17 from 9am - 5pm and Friday, September 18 from 9am - 5pm Training is held at the NCCJ Office (820 A Prospect Hill Road, Windsor, CT 06095) YES NO Question Title * 13. Do you acknowledge that this training cost $150 per person - that will go towards food and cost of program.That if you cannot pay this $150 you will notify Cynthia Martin (cmartin@nccj.org) immediately after submitting this form to see what can be arranged. YES NO Question Title * 14. Do you have any dietary needs? Question Title * 15. How does racism affect you personally? Question Title * 16. Why are you interested in attending this Anti-Racism Weekend Training? What do you hope to gain? Question Title * 17. Are there any topics or issues surrounding racism that you are interested in being addressed during the workshop? Question Title * 18. Anything else you would like us to know? Done