Registration Form
Thank you for your interest in this program! Please take your time in signing up, this info helps the 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 us at program@pjcvt.org or 802-863-2345 x6.

As a reminder, by filling out this form you are registering for a three-part facilitated discussion group held on Saturday, February 11, 18 and 25 from 3-5pm, at Town of Waterbury, Steele Community Room, 28 North Main Street, Waterbury. Guided by two facilitators, Isaiah Hines and Jade Walker, this discussion group is designed for all who are concerned about the impact of racism and/or white privilege on our children. We expect participants to attend all three sessions, this helps build connection and allow the full group to benefit from becoming more familiar with those in the conversation. Be sure to let us know if you need childcare in order for you to participate.

Name
Your answer
E-mail
Your answer
Phone
Your answer
Address
Please let us know what town you live in at the very least
Your answer
Are you a Peace & Justice Center member?
Standard Annual Memberships are $35 (individual), $60 (family) and $15 (fixed income or student)
Why are you interested in this discussion group?
What it the specific thing that inspoired you to sign-up today?
Your answer
What do you hope to take away from these discussions?
How do you plan to use the information in this group in your everyday life?
Your answer
How much can you contribute financially? The cost is $75 per person with a 20% discount for members. Consider covering the fee for another registrant. People age 24 and younger are not expected to contribute financially. No one will be turned away for lack of funds.
Please let us know if you have questions and/or need us to invoice an employer
Your answer
Do you require childcare in order to participate in this discussion group?
Please share with us the names and ages of the children who will be needing care during the sessions, as well as anymore information you would like to offer in regard to their care. Also please tell us the dates and times care is needed.
Your answer
Is there anything else you would like the discussion leader to know about you?
Your answer
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