2016 Fall Diversity Awareness Workshop Participant Interest Sheet

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Please complete this form by July 22, 2016 in order to be considered for the 2016 Fall Diversity Awareness Workshop. Notifications will be sent out in early August. If you are selected to participate, you will receive a confirmation letter with additional information. Those not selected this year will be notified and their names will be placed on our waiting list and will receive priority for future workshops.

Participant's name *

Title *

Dr.

Ms.

Mr.

Other:

Participant's department *

Participant's email *

Participant's telephone *

Dietary restrictions

Special needs/requested accommodations

Please check all of the following according to your availability: *

I am available to participate in the August 25 & 26 training

I am available to participate in the September 8 & 9 training

I would like to participate but I cannot attend either sets of dates

Required

Supervisor's name *

Supervisor's department *

Supervisor's email *

Supervisor's telephone *

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