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Race and Culture Study Circle Registration Form
* Indicates required question
First and Last Name
*
Your answer
Email
*
Your answer
City and State
*
Your answer
Phone number
Your answer
Please identify yourself
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White Participant
Ethnic Ally
If Ethnic Ally, what is your ethnic background?
Your answer
What is your median household income
*
$0-$24,999
$25,000-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000-$149,000
$150,000-$199,000
$200,00 or more
Where were you born? Where were you raised?
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Your answer
Spiritual/Religious Affiliation
Your answer
Why do you want to participate in the study circle?
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Your answer
What do you hope to gain by participating?
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Your answer
Are you willing to learn even if you feel uncomfortable?
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Yes
No
Maybe
If you are an ethnic ally are you willing to share your personal experience openly and honestly, albeit difficult?
Yes
No
Maybe
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Do you have any comments or questions?
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