Impacted Community Scholarship Registration for 2016 EJ Summit (online form)
18th NCEJN EJ Summit Registration (IMPACTED COMMUNITY SCHOLARSHIP -- Community members affected by environmental injustices)
Environmental Justice: Moving Beyond Electoral Politics and Toxic Representation
October 21-22, 2016
http://ncejn.org/
Contact ncejsummit@gmail.com with questions.
First Name
Your answer
Last Name
Your answer
Please share with us the impacted community you are from.
Your answer
Affiliation
Are you affiliated with a community group? If you have no affiliations that you would like to share with us, please put "N/A".
Your answer
Email Address
Please provide a working email address so we may verify your registration with you.
Your answer
Mailing Address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Phone
e.g., 999-999-9999
Your answer
Fax
Your answer
Impacted Community Scholarship Registration Type
Do you need lodging at the Franklinton Center on Friday night?
PLEASE NOTE: Lodging at the Franklinton Center will be reserved (FREE) for those requesting the Impacted Community Scholarship, then available rooms will be opened up to General Registrants (i.e. lodging for scholarships is not guaranteed after September 30). All Franklinton Center rooms will have at least 2 people per room. All registrants that have requested lodging at the Franklinton Center must notify the Coordinators by October 10 if lodging is no longer needed; otherwise, we will ask you to pay $25 for the dorm room and $40 for the hotel-style room.
Roommate Gender Preferences
If you would prefer to have a roommate of the same gender, please indicate below.
Name(s) of Roommate Preferences
Leave blank if not applicable. You may request up to 3 people. The hotel-style rooms have two double-size beds and a private bathroom.
Your answer
Do you have any dietary restrictions?
Please detail.
Your answer
Will you need child or adult care?
Please provide ages.
Your answer
How did you learn about the EJ Summit?
Would you like to make a donation?
There are many ways you can do so: PayPal (Go online to http://ncejn.org/ to PayPal ncejnetwork@gmail.com), Check (Mail to: P.O. Box 68, Rocky Mount, NC 27802), Money Order (Mail to: Box 68, Rocky Mount, NC 27802), or On-site cash. You may make the check or money order to NCEJN.
I approve of being photographed or filmed at the 2016 EJ Summit.
Submit
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