*Your name:

*Department:

*E-mail addresss:

*Phone Number:

The following information is optional. Please only fill in categories you are comfortable sharing with us. This information helps us plan for a diverse learning group.

Race:

Ethnicity:

Sex:

Gender:

Sexual orientation:

Class:

Religion/Spirituality:

(dis)Ability:

Please feel free to provide a category that we have not included and corresponding information that you are comfortable sharing:

We will confirm your participation prior to the training. We look forward to working with you! Please let us know if you have any questions.