* 1. First & Last Name:

* 2. Preferred Name:

* 3. Student ID #:

* 4. E-mail address:

* 5. Department:

* 6. Program:

* 7. Which sessions will you be attending? (You need to attend all 3 workshops to complete the certificate program).

* 8. The DEO strives to create inclusive programming for everyone. Do you have any accessibility concerns which we can address?

T