Registration - Madison, WI Institutes for the Healing of Racism, Inc.

This series will be held on Mondays: September 16th to November 18th, 2019 at the Urban League of Greater Madison, 2222 S Park Street, Suite 200.

A ten-week commitment is required for full understanding and impact. Please wait until the spring series 2020 if you believe you may miss more than two sessions this fall.

Registration Fee $50.00 (need-based scholarships are available. For scholarship info, contact healingracisminstitute@gmail.com).

Payment is to be made on the first night of the session by cash or check.

Preferred First Name *
Enter your legal name, nickname, or preferred name
Your answer
Last Name *
Enter your last name
Your answer
Email Address *
Enter your email address
Your answer
Primary Phone Number *
Enter your primary phone number, including area code (e.g., 608-466-2853)
Your answer
Alternate Phone Number
Enter an alternate phone number if you have one (include area code)
Your answer
Age
Enter your age using only numbers (you must be 16 or older to participate)
Your answer
Ethnicity
Enter your ethnicity or ethnicities
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service