Registration - CCC + LGBTQ Summit 2017

Please complete the form below to register to attend the CCC + LGBTQ Summit, November 11, 2017 at UC Riverside. This higher education conference will bring together students, faculty, staff, and advocates to address efforts to support and create resources for LGBTQ people at California Community Colleges.

The Summit is a free event. More information about the Summit is online at cccqsummit.blogspot.com

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* 1. Full Preferred Name:

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* 2. E-mail Address

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* 3. Please re-enter your email address:

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* 4. Campus Name (please select "Campus Not Listed Above" at the bottom of the list if your campus is not listed, then enter the name of your campus in the text box):

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* 5. What is the city, state and zip code of your campus/organization?

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* 6. Campus Status:

Undergraduate Student

Graduate Student

Staff

Faculty

Administrator

Community Member (not affiliated with any campus)

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* 7. Please select your Subway sandwich box lunch (unless noted, served with chips & a chocolate chip cookie):

Ham & cheese

Ham and no cheese

Turkey & cheese

Turkey and no cheese

Veggie Delight & cheese

Veggie Delight and no cheese - apple slices instead of cookie - VEGAN

Salad with chicken (no sides) - GLUTEN-FREE

Salad without chicken (no sides) - GLUTEN-FREE, VEGAN

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* 8. We will hold concurrent Caucus spaces for 75 minutes in the afternoon to dialogue around next steps for CCC addressing LGBTQ inclusion and resources. What Caucus space are you most likely to attend?

Students

Faculty

Staff

Administrators

None of these caucus spaces interest me or I wish to recommend a different space (Please comment further):

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* 9. Please share your needed ADA-related accommodations. If you do not need accommodations for disabilities, please check NO. If yes, please share needed accommodations.

Yes - Please Share:

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* 1. Full Preferred Name:

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* 2. E-mail Address

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* 3. Please re-enter your email address:

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* 4. Campus Name (please select "Campus Not Listed Above" at the bottom of the list if your campus is not listed, then enter the name of your campus in the text box):

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* 5. What is the city, state and zip code of your campus/organization?

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* 6. Campus Status:

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* 7. Please select your Subway sandwich box lunch (unless noted, served with chips & a chocolate chip cookie):

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* 8. We will hold concurrent Caucus spaces for 75 minutes in the afternoon to dialogue around next steps for CCC addressing LGBTQ inclusion and resources. What Caucus space are you most likely to attend?

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* 9. Please share your needed ADA-related accommodations. If you do not need accommodations for disabilities, please check NO. If yes, please share needed accommodations.

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* 10. Do you have any questions or concerns?