East Ed: Eastern Educational Resource Collaborative

East Ed Conference Registration

Middle School Student Diversity Leadership Conference
North Carolina
Thursday, March 15, 2012

Canterbury School
5400 Old Lake Jeanette Road
Greensboro, NC 27455

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 $40 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: