Home	Registration

Fourth White Anti-racist Summit

Registration Form

1. Print this form

2. Complete the information.

3. Mail completed form and payment to:

Center for Study

Attn: Summit & WPC9

245 West 4th Avenue

Roselle, NJ 07203

or fax (credit card pmt. only) to 908.245.4972

First Name:	______________________ MI ______ Last Name ______________________________
Title:	__________________________________________________________
Organization/School:	__________________________________________________________
Address:	__________________________________________________________
	__________________________________________________________
City:	__________________________________________________________
State:	_________________________ Zip: __________________________
Telephone:	__________________________________________________________
Email:	__________________________________________________________

Will you you require ADA compliant accomodations? (circle): Yes No

Please describe: _________________________________________________________

Are you attending the summit as a representative of a group? (circle): Yes No

Name of your group: __________________________________________

Location of group (city and state, or region): ________________________________________

Is your group a white anti-racist group? (circle): Yes No

Is your group a multiracial anti-racist group? (circle): Yes No

Other ____________________________________

Optional: Demographic information is needed for grant requests and research by WPC9. This information will not be electronically attached to your registration information/name/address/institution/etc.

Age (check one)

___ 14-20

___ 21-29

___ 30-39

___ 40-49

___ 50-59

___ 60-69

___ 70-79

___ 80+

Gender (check one)

___ Female

___ Intersex

___ Male

___ Transgender

___ Other

Race (check one)

___ Multi-Racial

___ Hispanic/Chicano/Latino

___ American Indian/Alaska Native

___ Asian American or Pacific Islander

___ African American/Non-Hispanic

___ White/Non-Hispanic

___ Other

Sexual Orientation (check one)

___ Bisexual

___ Heterosexual

___ Gay

___ Lesbian

___ Questioning

___ Other

Household Income (check one)

___ $0 - $10000

___ $10000 - $20000

___ $20000 - $30000

___ $30000 - $40000

___ $40000 - $50000

___ $50000 - $60000

___ $60000 - $70000

___ $70000 - $80000

___ $80000 - $90000

___ $90000 - $100000

___ $100000+

WPC's attended (check one)

___ 1st

___ 2nd

___ 3rd

___ 4th

___ 5th

___ 6th

___ 7th

___ 8th

___ 9th

Meal preference (check one)

___ A variety of tuna, turkey, & chicken sandwiches or salads

___ Vegetarian (NOT Vegan)

Dietary Restrictions (i.e. Vegan, Gluten free, etc.):

________________________________________________________________

Registration fee (full payment must accompany registration form).

	Until March 14	After March 14
Regular	75	90
Student	50	55

- OR -

Register for Summit & WPC9 together (Circle rate)
This registration option is limited to the first 50 people. To check on availability,
email admin@wacan.org, or call 908.241.5439.

	Until March 14	After March 14
Regular	175	200
Student	125	130
______ Check here and include an additional $5 if you want to attend the Shabbat Banquet on Friday, April 4.

Total registration fee: _______________

Payment

By credit card (circle one)

Visa MasterCard American Exp. Discover

_______________________________________
Card No

_______________________________________
Expiration mo./yr.

_______________________________________
Name on card (if different than above)

_______________________________________
Signature/date

By check (registration by mail, only)

Please make check payable to “Center for Study”

Confirmation of registration

You will receive confirmation and receipt for payment via email.

Cancellation Policy

Cancellations must be made in writing and postmarked Wednesday, March 26, 2008 to receive full refund minus a cancellation fee ($30 non-student; $10 student). For those exceptional circumstances, 75 percent refunds may be available until Monday, March 31, 2008. Refunds will be made by check from the Center for the Study of White American Culture, Inc. and will be mailed within 30 days following the Fourth White Anti-racist Summit and WPC9.