Youth Action for Social Justice

East Ed Conference Registration


Middle School Student Diversity Leadership Conference
Wednesday, April 18, 2012

St. David's Episcopal Church
301 E 8th Street
Austin, TX 78701
Parking lots near premises

Registration opens at 8:30
Program begins at 9:00 am
Closing at 2:00 pm
Breakfast, Lunch and snacks provided

Limited scholarships available.
Contact: Stephanie Nestlerode at:
512-925-1360

View Flyer




School Information

School Name:

Phone #:     Fax #:

Street Address:

City:     State:     Zip:



Faculty Diversity Contact

Name:
Position:
Phone #:     Email:

Registration

1. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

2. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

3. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

4. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

5. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

6. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

7. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

8. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

9. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

10. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

11. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

12. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

13. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

14. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

15. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

16. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

17. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

18. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

19. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

20. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

21. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

22. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

23. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

24. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:

25. StudentAdult
     First Name:
   Last Name:
     Gender:
   Grade: Age:
     Email:    Food Notes:
     Race (select one):
     If other, please specify:
     T-Shirt Size:


The conference fee for adults and students is $45 per person.

Payment can be made by check or credit card.
Credit cards can be presented on site.

Checks should be mailed to:
East Ed, PO Box 57011, Washington, DC 20037

Indicate payment type: