Registration Form

A Non-Residential Group Relations Conference

Authority and Leadership: Perspectives on Diversity

May 19-21, 2006
Howard University College of Dentistry
Washington , DC

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 inform the work of staff and to form homogeneous Role Review 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 May 8, 2006. The letter may be submitted by email to crawford.candice@gmail.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 April19, 2006
$425, if received/postmarked after April 19, 2006 and by May 8, 2006

$50 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 May 8, 2006)
$75 deposit with letter requesting reduction of conference fees [Letter must by received/postmarked by May 8; letter may be submitted by email to crawford.candice@gmail.com.]
Total fees/deposits enclosed: 
 
Withdrawal policy: An administration fee of $75 will be retained if the application is withdrawn prior to or on May 8, 2005. No refunds will be issued after this date.
 
Payment
Enclosed check payable to WBC, for $__________
  VISA MasterCard  
Name on Card ______________________________
Card # ______________________________
Exp. Date ______________________________

Security Code (This is the last three digits of the number in the signature box on the back of the card)

______________________________
Amount $ ______________________________
Signature of cardholder ______________________________
I have read the description of this learning event in detail and hereby apply for participation. 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 entire fee or deposit 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:

Candice A. Crawford, Administrator
Washington-Baltimore Center for the Study of Group Relations
1301 Connecticut Avenue, NW Suite 750
Washington DC 20036

Email: DiversityConf@wbcgrouprelations.org
Phone: 202-887-8955, Ext. #1
Fax: 202-429-0102

 
The Washington-Baltimore Center for the Study of Group Relations