LEARNING CIRCLE SERIES 2009
Residential Trainings Application Form

 

Choose your training(s):

 Communications for Racial Justice
Thursday, January 23, through
Sunday, January 26, 2009


   Contact Information: (* denotes required information)

First Name*:

Last Name*:

Title:

Organization or Group*:

Street Address*:

Suite, Floor, or Unit:

City*:

State*:

Zip Code*:

Telephone (work):

Telephone (cell):

Fax:

E-Mail*:

Website:
BACKGROUND INFORMATION (optional)
While providing the following information is optional, it will help us ensure that a broad range of perspectives is represented at the trainings and there is diversity within the participant pool.

Age: Under 25 25-40 41-55 56 or over No Answer

Differently-Abled: Yes No No Answer

Gender: Male Female Transgender No Answer

Sexual Orientation:
Heterosexual Gay/Lesbian Bisexual Other No Answer

Race (please check all that apply):
African American/Black Asian/Pacific Islander Latino/Hispanic
Native American/American Indian Caucasian/White Multiracial
Other

ORGANIZATIONAL INFORMATION

1. Please specify the issue areas your organization works on.

2. Please describe your role in the organization.

POPULATION DEMOGRAPHICS & GEOGRAPHIC AREA
Organization type (check all that apply):
Community-based Organization
Grassroots membership-based Organization
Coalition/Network
Local/State Health Organization
National Health Organization
Policy Group
Government Agency
Foundation
Other
Service area of your organization (check all that apply):
Rural
Urban
Suburban
Local
State
Regional
National
What population(s) does your organization/agency serve? (check all that apply)
African American/Black Asian/Pacific Islander Latino/Hispanic
Native American/American Indian Caucasian/White Multiracial
Other

Number of staff at your organization:

Are other staff members of your organization applying to this residential training?
Yes No No Answer

Please give a brief description of the policy and/or organizing experience that you and your organization have(less than 100 words, please):

What do you hope to gain from attending the training?
How did you hear about The Praxis Project In-Residence Trainings? (please check all that apply)
Praxis Staff
Praxis Mailing List
Praxis Newsletter
Praxis Website
Other Listserv/Mailing List
Other Newsletter
Other Website
Advertisement
Funder Referral
Other Referral
Other

FINANCIAL ASSISTANCE

Do you require financial assistance to be able to attend the training?
Yes No No Answer

What is your organizations annual budget: $