Registration Form
Thank you for your interest in attending the "Building Empathy and Addressing Racial Oppression" workshop. Please fill out the following registration form to the best of your ability, in order to help facilitators better meet the needs of individuals in the group while keeping in mind the overall goals and mission of the program. If you have any questions at all and/or if there is a error in this form please contact program@pjcvt.org or call 802-863-2345 x6

Please be aware that this is a three part workshop, and participants are expected to attend all three parts. As a reminder, these sessions are on Wednesdays, January 11, 18, and 25, from 6:30-8:30pm at Memorial Hall in Essex. This program strives to give participants the opportunity to build skills and knowledge to engage in conversations about racism and action that addresses racial oppression. This program is being presented in partnership with Heart and Soul of Essex and the Essex Community Justice Center
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Name *
E-mail *
Phone
Address *
Please let us know what town you live in at the very least
Are you a Peace and Justice Center member? *
If you would like to learn more about membership visit: http://www.pjcvt.org/get-involved/become-a-member/ 
Why are you interested in this workshop?
What is the specific thing that inspired you to sign up?
What do you hope to take away from this workshop?
How do you plan to apply the information learned from this workshop to everyday life?
Is there anything else you would like the workshop facilitator to know about you?
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