Registration Form

A Non-Residential Group Relations Conference

Authority, Leadership, Power & Resources: Perspectives on Diversity

June 25-27, 2004
Howard University College of Dentistry
Washington, DC

Five convenient ways to register:
(1) Register online and use PayPal to pay by credit card on a secure server
(2) Register online and mail/fax your credit card information
(3) Register online and mail your check
(4) Print this form, register by mail/fax and include your credit card information
(5) Print this form, register by mail and include your check

Application for Membership and Conference Policies

 

* Title Dr. Ms. Mr.
Other
* Name
Address
City
State
Zip
E-mail
Phone
* Employer/ Org. Affiliation
The information marked with a * will be given to all members of the conference.
 
The information below will be used only to form homogenous
Role Analysis and Application Groups.
Age
Gender Identity
Race/Ethnicity
Sexual Orientation
Work Role
Previous Group Relations Conference Experience? 0 1 2 3+
Other Differences and/or Aspects of Identity
 
Reference Letter Policy: Each applicant must provide a written letter of reference from someone, preferably in her/his organization, who can confirm the applicant’s capacity to participate in an intense learning experience. It is the applicant’s responsibility to assure that this letter is submitted by June 15, 2004. The letter may be submitted by email to WBCDiversity04@aol.com. A reference letter will be forwarded by:
Name
Phone/E-mail
 
Attendance Policy: Individuals who know in advance that they are unable to attend all sessions are discouraged from applying because the conference events are connected and together create the temporary institution. Also, because experiential learning events of this kind may be stressful, individuals who are ill or experiencing a period of personal difficulty may wish to forgo attendance at this time.
 
Conference Fees:
$395, if received/postmarked on or before May 21, 2004
$425, if received/postmarked after May 21, 2004 and by June 15, 2004

$25 discount for three or more persons applying as a group from the same institution

$40 discount for members of A.K. Rice Institute for the Study of Social Systems
$40 discount for full-time students (submit copy of current ID)
$75 non-refundable deposit reserves a place at the conference (balance due by June 15)?
$75 deposit with letter requesting reduction of conference fees [Letter must by received/postmarked by May 21; letter may be submitted by email to WBCDiversity04@aol.com.]
Total fees/deposits enclosed:
 
Withdrawal policy: An administration fee of $30 will be retained if the application is withdrawn prior to or on June 15, 2004. No refunds will be issued after June 15, 2004.
 
Payment
Enclosed check payable to Washington Baltimore Center, for $__________
  VISA MasterCard  
Name on Card ______________________________
Card # ______________________________
Exp. Date ______________________________
Amount $ ______________________________
Signature of cardholder ______________________________
I have read the brochure for this conference in detail and hereby apply for membership. I understand that this brochure constitutes the contract between me and Washington Baltimore Center and that my application authorizes the organization to conduct the conference in the manner described. My conference fee, deposit or voucher accompanies this application. I understand and agree to all policies stated on this application form.
Signature _________________ Date___________
 

Instructions:
If you are going to fax or mail in your registration, then print this page
and fax it to the number below and click Proceed.
If you are going to register online, then click Proceed to continue
and use the secure transaction server at PayPal
to enter your credit card data.

 

Send this form with payment and all documentation to:

Kimberley A. Turner, M.Ed., Associate Director for Administration
P.O. Box 77051
Washington DC 20013

Email: WBCDiversity04@aol.com
Phone: 202-887-8955
Fax: 202-833-9177

 
The Washington-Baltimore Center for the Study of Group Relations