General Registration for 2017 EJ Summit (online form)
19th NCEJN EJ Summit Registration (GENERAL -- Lodging NOT included in registration fee)

Building People’s Power Against State Violence Through the Lens of Environmental Justice
October 20-21, 2017
http://ncejn.org/
Contact ncejsummit@gmail.com with questions.

Email address *
First Name *
Your answer
Last Name *
Your answer
Organization *
Are you affiliated with a community group, university, nonprofit organization, governmental agency, etc.? If you have no affiliations that you would like to share with us, please put "N/A".
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
General Registration Type *
Please Note: Lodging NOT included in registration fee.
Method of Payment *
Please make check or money order to NCEJN.
Would you like to be added to the wait list for Franklinton Center Friday night lodging? *
Lodging at the Franklinton Center will be reserved for those requesting the Impacted Community Scholarship and the Student Work Exchange until September 30, then available rooms will be opened up to General Registrants. Those that are General Registrants and would prefer to stay at the Franklinton Center will be put on a waiting list. On October 1, any available rooms on-site will be assigned to the General Registrants on the waiting list. Dorms will cost $25 per person and hotel-style rooms will cost $40 per person. Please fill out the "Lodging Survey" so that we may accommodate you as best as possible. All Franklinton Center rooms will have at least 2 people per room. People that do not want to stay on-site or that need to have lodging secured prior to October can reserve a room at the Country Inn & Suites (Please refer to the website for further details).
Do you have any dietary restrictions?
Please detail (e.g. vegetarian).
Your answer
Will you need child or adult care?
Please provide ages.
Your answer
Would you like to make a donation? *
There are many ways you can do so: PayPal/ credit card (Go to https://tinyurl.com/NCEJN-money), 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.
How did you learn about the EJ Summit?
I approve of being photographed or filmed at the 2017 EJ Summit. *
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms