Application - Madison Wisconsin Institutes for the Healing of Racism, Inc.
Weekly meetings 6-8 pm for ten weeks. Choose either Wednesdays (February 15 – April 26) or Thursdays (February 16 – April 27). Note there is no class the week of April 10-14 due to MMSD spring break.

A ten-week commitment is required for full understanding and impact. Please wait until the fall series if you believe you may miss more than two sessions this spring.

Registration Fee $50.00 (need-based scholarships are available. For scholarship info, contact healingracisminstitute@gmail.com).

Payment will be accepted once your enrollment is confirmed.

Preferred First Name *
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Last Name *
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Email Address *
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Address Line 1 *
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Address Line 2
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City *
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State *
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ZIP / Postal Code *
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Primary Phone Number *
Enter your primary phone number, including area code (e.g., 608-466-2853)
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Alternate Phone Number
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Age
Enter your age using only numbers (you must be 16 or older to participate)
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Ethnicity
Enter your ethnicity or ethnicities
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Are you a past participant? *
If yes, would you be willing to share your experiences from past sessions with the group?
How did you hear about the Spring 2017 series?
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Which day works best for you?
What do you expect/hope to get out of participation in the Institutes?
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Will you have any barriers to accessing online assignments during the 10-week session? If yes, please explain. *
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Gender Pronoun Preference
Select your preferred gender pronouns from the list or choose "Other" and indicate your preference
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