Impacted Community Scholarship Registration for 2019 EJ Summit (online form)
21st NCEJN EJ Summit Registration (IMPACTED COMMUNITY SCHOLARSHIP -- Community members affected by environmental injustices)
Reclaiming Our Power
October 18-19, 2019
Please share with us the impacted community you are from.
Are you affiliated with a community group? If you have no affiliations that you would like to share with us, please put "N/A".
Please provide a working email address so we may verify your registration with you.
Impacted Community Scholarship Registration Type
Friday only (FREE)
Saturday only (FREE)
Friday + Saturday (FREE)
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
), 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.
Yes, I would like to make a donation to NCEJN.
Maybe, I will consider.
No, thank you.
Would you like to nominate someone to receive an NCEJN Award?
Steve Wing International EJ Award, NCEJN Community Resilience Award, EJ Youth Vanguard Award
Yes, I have someone for nomination.
Maybe, I'll consider someone.
How did you learn about the EJ Summit?
NCEJN Facebook page
Online, not through NCEJN's sites
From a friend or family member
From my community organization
From a listserv email
From a flyer
I approve of being photographed or filmed at the 2019 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.
No, thank you.
Yes, please. Please fill out the below information.
What type of room at the Franklinton Center do you need?
Hotel-style room (2 double beds and a private bathroom; minimum per room=2)
Dorm-style room (2 single beds and a shared hallway bathroom; minimum per room=2)
Either style works for me
Would be willing to sleep on the floor at the Franklinton Center?
Yes (This means you need to provide your own bedding and towel).
Are you interested in camping outside on the historic lands of the Franklinton Center under the stars?
Maybe, if there is no other space onsite.
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.
Page 1 of 2
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service