Exploring Race and Racism in the United States Intergroup Dialogue Weekend Course Spring 2018
The following information will assist us in putting together a balanced, diverse group for each intergroup dialogue section.
All information will be kept confidential.
Please return this form to the Division of Student Life Suite, Blanchard Community Center

NOTE: PLACEMENT IS CONSIDERED ON A FIRST-COME, FIRST-SERVED BASIS WITHIN THE LIMITS OF REASONABLE GROUP SIZE AND COMPOSITION (20 students maximum)

This course is a prerequisite to an 8 week STUDENT FACILITATOR TRAINING COURSE Spring 2018, designed for students interested in learning how to facilitate intergroup dialogues.

DEADLINE FOR ALL APPLICATIONS IS January 13, 2018, 5:00pm
Instructors: Marcella Runell Hall
Molly Keehn
Latrina L. Denson

For additional information, contact Latrina L. Denson at ldenson@mtholyoke.edu.

Email address *
NAME (First and Last) *
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Student ID *
Your answer
Telephone Number
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What is the best way to reach you? *
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What college/ university do you attend? *
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What year are you? *
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This course can be taken as a non-credit or a one (1) credit course. Please check YES if you would like to take the course as credit and NO if you would like to take the course as non-credit. NOTE: If you check YES, you will automatically be enrolled in the course. Therefore, please review the syllabus in detail before confirming that you will take the course for credit at: https://sites.google.com/view/mtholyokeigd/home?authuser=0. *
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Pronouns (optional)
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Race/ Ethnicity *
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U.S. Status *
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Religion/ Faith *
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Disability status (specify) *
Your answer
Class/Socioeconomic status *
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What do you hope to learn/gain from your participation in this intergroup dialogue? *
Your answer
What are your concerns about participating in this intergroup dialogue? *
Your answer
Is there anything else you would like us to know about you or your interest in the course? *
Your answer
Are you interested participating in the IGD Facilitation course, which begins Wednesday evenings, February 14 (time and location to be determined).
By checking YES below, I confirm that if selected, I will participate in the "Exploring Race and Racism Weekend Dialogue Course, February 3-4, 2018. *
Required
By checking YES below, I agree to notify the instructors no later than Friday, January 26, 2018, 5:00pm by emailing ldenson@mtholyoke.edu if some reason I can no longer participate in the course. *
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