Work that Reconnects Registration
November 16th 2019 9am - 5pm at the Unitarian Universalist Society of Mill Creek
579 Polly Drummond Hill Rd, Newark, DE 19711
Email address *
Name *
Your answer
Address *
Your answer
What brings you to attend this workshop? And what do you hope to gain or learn from it? *
Your answer
Social Identity: we are interested to learn more about your identity, so that we can hold awareness of who is in the room and work toward a more inclusive language. Everyone is welcome. Please respond only to what you are comfortable answering. All responses will be held in confidence.
What is your gender?
Your answer
What gender pronouns do you prefer?
Your answer
What is your age?
Your answer
What is your racial identity? What is your ethnic identity? Where do your ancestors come from?
Your answer
What is your religious or spiritual affiliation or practice, if any?
Your answer
What is your sexual orientation?
Your answer
What is your current socio-economic identity?
Was your childhood socio-economic situation substantially different from your current situation? If so, how?
Your answer
What is your educational background? What degrees or certifications have you completed?
Your answer
What is your profession, your current work or passion?
Your answer
Do you identify yourself as a person with a disability? If so, do you have any special needs that we need to be aware of in order for you to participate with ease?
Your answer
Do you wish speak to an area of your identity that is important to you that was not mentioned?
Your answer
We are going to offer a light vegan lunch and snacks. Please indicate any specific dietary needs we should be aware of.
Your answer
We very much want all who want to attend this workshop to be able to do so. The cost of this workshop to help cover our costs, food, time and materials and donation to the church is a sliding fee scale from $150 to $50.
Please indicate the amount you commit to pay by Nov 6th 2019. *
Your answer
If you are not able to pay this due to your situation, and require further fee reductions in order to attend, please indicate the amount you can pay and by when and we will do our best to accommodate.
Your answer
Please send registration form and a check for payment if possible by Nov 6th 2019. Credit Card processing will not be available.
Please make checks payable to Julia Smagorinsky and send to 309 Beech Lane, Kennett Square PA 19348.
Thank you for your registration. We are looking forward to see you on November 16th. Please plan to arrive 10 minutes early. Judy and Julia
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy