General Registration for 2019 EJ Summit (online form)
21st NCEJN EJ Summit Registration (GENERAL -- Lodging NOT included in registration fee)

Reclaiming Our Power
October 18-19, 2019
http://ncejn.org/
Contact ncejsummit@gmail.com with questions.
Email address *
First Name *
Last Name *
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".
Mailing Address *
City *
State *
Zip *
Phone *
e.g. 999-999-9999
Fax
General Registration Type *
Please Note: Lodging NOT included in registration fee.
Method of Payment *
Please make check or money order to NCEJN.
Do you have any dietary restrictions?
Please detail (e.g. vegetarian).
Will you need child or adult care?
Please provide ages.
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.
Clear selection
Would you like to nominate someone to receive an NCEJN Award?
Steve Wing International EJ Award, NCEJN Community Resilience Award, EJ Youth Vanguard Award
Clear selection
How did you learn about the EJ Summit?
Clear selection
I approve of being photographed or filmed at the 2019 EJ Summit. *
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 2, 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 below information 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).
What type of room at the Franklinton Center do you need?
Clear selection
Would you be willing to sleep on the floor at the Franklinton Center?
Clear selection
Are you interested in camping outside on the historic lands of the Franklinton Center under the stars?
Clear selection
What is your gender?
Clear selection
Roommate Gender Preference
Clear selection
Name of preferred roommate(s).
We are trying to accommodate as many people as possible onsite. You must have at least one roommate.
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy