East Ed Conference Registration

High School Student Diversity Leadership Conference
Thursday, April 15, 8:30 - 2:00

All Souls Church
2835 16th Street, NW
Washington, DC 20009

Facilitator training will be:
Saturday April 10th
10:00 - 12:00----OR----1:00-3:00

School Information

School Name:

Phone #:     Fax #:

Street Address:

City:     State:     Zip:

Web Address:

Head of School:

Faculty Diversity Contact

Name:
Position:
Phone #:     Email:

Registration

1. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

2. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

3. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

4. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

5. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

6. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

7. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

8. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

9. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

10. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

Payments ($40 per participant) should be mailed to:
East Ed
P.O. Box 57011
Washington, DC, 20037