Black Community Retreat 2018 Participant Application Form
ABOUT BLACK COMMUNITY RETREAT 2018:
The Black Community Retreat is an off-campus retreat for revitalizing the bonds of the African Diasporic community. We hope to create a sense of union, and to form leaders and pioneers for our community!

THEME: Building Bridges, Building Unity

RETREAT INFORMATION:
Saturday, October 20 AND Sunday, October 21
Location: Community of the Great Commission - Foresthill, Ca (transportation will be provided)

APPLICATION DUE DATE:
Applications are due by Sunday, October 14th at 11:59pm. All applicants will be notified of their application status by Monday, October 15th.

PARTICIPATION FEE: There is a $20 fee for the entire retreat, which covers transportation, lodging, and food. There will be more information provided once there has been final confirmation on participants. If you absolutely cannot afford this fee, we still encourage you to apply and we will offer fee waivers later!

QUESTIONS/COMMENTS:
Please direct any inquiries regarding the retreat to our staff at dmpomar@ucdavis.edu

THIS FORM WILL TAKE APPROXIMATELY 10-15min. TO COMPLETE
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General Information
Preferred First Name *
Last Name *
Pronouns *
How would you like others to refer to you in the third person? Examples: she/her, he/him, they/them, ze/zir, etc.         https://lgbtqia.ucdavis.edu/educated/pronouns
UC Davis Student ID *
Please ensure that you are entering an accurate, 9-digit ID number. This information will not be shared with anyone.
E-mail Address *
Best Phone Number to Reach You *
Example: (123) 456-7890. This will not be shared with anyone and only used to contact you if you don't respond via e-mail.
Student Status at UC Davis *
Please note that priority registration is given to first year freshmxn & transfer students.
Meal Preferences
Please indicate any allergies in the "other" option.
Clear selection
Do you have any medical or health conditions that we should be aware of? *
Examples: ongoing medical conditions, different abilities, or other circumstances that require special accommodation(s)? Please be specific.
Will you be 18 or older at the time of our retreat? *
**lf under 18 years of age, a signature of parent or guardian is necessary**
Indicate your housing preference. *
During this overnight retreat, participants will be sharing a room with others. Please indicate your preference for a roommate/roommates.
Emergency Contact Information
First Name & Last Name of Emergency Contact #1 *
Relationship of Emergency Contact #1 to You *
Emergency Contact #1 Phone Number *
Example: (123) 456-7890
First Name & Last Name of Emergency Contact #2 *
Relationship of Emergency Contact #2 to You *
Emergency Contact #2 Phone Number *
Example: (123) 456-7890
Short Response Questions
Tell us a little bit about yourself (background, goals, major/minor, interests, hobbies, and what makes you, YOU!) *
What is your Zodiac Sign?                                                   *
Statement of Agreement *
PLEASE READ THE FOLLOWING STATEMENT:If I am selected to participate, I agree to follow all University Policies and Guidelines including support for the principles of community, abstaining from alcohol consumption, and engaging in the use of illegal drugs while attending the conference. Furthermore, I understand that I am committed to attending the entire retreat. Early departure will not be allowed, unless there is an emergency.By typing your name on the signature line, you verify yourself as the named applicant and agree to all information and policies outlined in this application.
Consent and Use of Likeness *
When we need to use someone's image (for instance, a photograph or video) in a publication, like a newsletter, magazine or website, a Release for Use of Likeness gives us permission from the person in that image.The SRRC will: take staff photos and post them on the SRRC website, release occasional newsletters with pictures of staff and/or participants, and potentially publish other items with your image or likeness.Please read the statement and provide your consent if possible. If you have any questions, let us know. If you do not consent to use of likeness, please do not sign.In consideration of my participation for this event, I, the undersigned, hereby expressly and irrevocably consent to be filmed/videotaped/photographed and/or audiotaped. I agree that UC Davis will own any and all rights in said film/video/photography and/or audio recording, and I waive any and all uses of my name, likeness, voice, or character including but not limited to, the right to reproduce, distribute, sell, transmit, publish, exhibit, or otherwise use any of the above. I understand that in proceeding with said multimedia, UC Davis and the Student Recruitment and Retention Center is doing so in full reliance on the foregoing permission.I release whatever rights, title, or property interest I may have in the production, or so much of it pertains to me.
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