1. Name
First *

Last * 

2. MHC Email *

3. Contact
A. Phone Number *

B. Phone Type: * Cell Home Other

4. Identity
Again, all information is voluntary, please supply as much of the following information as you feel comfortable sharing about your identity. Information is kept strictly confidential.

A. Ability
(example: able bodied, learning disability, etc.)

B. Age  

C. Class/Socio-Economic Status *
(example: poor, lower working-class, middle-class, upper-class, etc.)

D. Gender
(example: female, male, transgender, etc.)

E. Race *

F. Religion/Spirituality

G. Sexual Orientation
(example: heterosexual, gay, lesbian, bisexual, questioning, etc.)

5. Please answer the following questions:

A. What do you hope to bring to the dialogues? *

B. How do you hope you will be affected by the dialogue? *

C. Is there anything else you would like us to know about you? *

6. Topic and Time Preferences

Please check all that you are able and willing to participate in:

A. Faith/Belief Intergroup Dialogue
Mondays, 4-6:30 pm (First Dialogue: Monday, September 21)

B. Ability Intergroup Dialogue
Mondays, 7 - 9:30 pm (First Dialogue: Monday, September 21)

C. Sisters of the Yam Women of Color Intragroup Dialogue/Book Study
Thursdays, 4- 6:30 pm (First Dialogue: Wednesday, September 23)

D. GLBT/ Heterosexual Intergroup Dialogue
Tuesdays, 7 – 9:30 pm

E. Race/Class
Thursdays 4- 6:30 pm (First dialogue: Thursday, September 24)