Impacted Community Scholarship Registration for 2018 EJ Summit (online form)
20th NCEJN EJ Summit Registration (IMPACTED COMMUNITY SCHOLARSHIP -- Community members affected by environmental injustices)


Making Revolution Irresistible: A Summit Celebrating Promise, Change & Action
October 19-20, 2018
http://ncejn.org/
Contact ncejsummit@gmail.com with questions.

Email address *
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 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.
Would you like to nominate someone to receive an NCEJN Award?
Steve Wing International EJ Award, NCEJN Community Resilience Award, EJ Youth Vanguard Award
How did you learn about the EJ Summit?
I approve of being photographed or filmed at the 2018 EJ Summit. *
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, you will be required to pay $25 for the dorm room and $40 for the hotel-style room.
What type of room at the Franklinton Center do you need?
Would be willing to sleep on the floor at the Franklinton Center?
Are you interested in camping outside on the historic lands of the Franklinton Center under the stars?
What is your gender?
Roommate Gender Preference
Name of preferred roommate(s).
We are trying to accommodate as many people as possible. You must have at least one roommate.
Your answer
A copy of your responses will be emailed to the address you provided.
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