White People Confronting Racism - March 20-22, 2020

Learn more about this workshop at: whitesconfrontingracism.org

Contact whitesconfrontingracism@gmail.com with questions about this registration form.

Registration - Contact Info + Dietary Preferences

First Name *

Middle Name

Last Name *

Personal Pronouns (i.e. he/him, she/her, they/them, etc.)

Email Address *

Phone Number *

Work Phone Number

Address *

Address Line 2

Address Line 3

City *

State *

Postal Code *

Country *

Dietary Preference(s) (Choose all that apply) *

Other dietary needs (optional)

Credit Card Information

Card Type

Card Number *

Security Code *

Expiration Date *

My billing address is the same as above

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Province *

Postal Code *

Whites Confronting Racism - Registration Questions

What group or organization do you work with? Please choose 1 primary organization. (Optional)

Have you ever taken an anti-racism workshop before? If so, where? *

Please tell us a bit about why you want to come to the Whites Confronting Racism workshop: *

Anything else you would like us to know?