July 16, 2011-Boys of Color: Perilous Times II Registration Survey

Please complete the following information.(Required.)

*First name:

*Last name:

Organization or Community:

Mailing Address:

City, State:

Zip Code:

*E-mail address:

Phone number:

Youth will play an integral role in this conference. As a youth-serving organization, we would ask that you bring no more than 10 boys, ages 11-18, to join us for the day. We will ask that you provide a list of participant names no later than 2 days before the conference so that name tags are available. Please provide participant names if available:

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We would like to connect conference attendees with the myriad of resources already available in the community. If you are attending the symposium as a representative of a particular organization or institution, please take a moment to provide the following information so that we can share this with everyone in attendance.

Organization Mission:

Organization Website:

Programs/services provided that target black and brown boys: