Student Nation

East Ed Conference Registration


Middle School Student Diversity Leadership Conference
Tuesday, February 10

School Information

School Name:

Phone #:     Fax #:

Street Address:

City:     State:     Zip:

Web Address:

Head of School:

Faculty Diversity Contact

Name:
Position:
Phone #:     Email:

Registration

1. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

2. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

3. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

4. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

5. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

6. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

7. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

8. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

9. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

10. StudentAdult
     First Name:    Last Name:
     Gender:    Grade: Email:
     Food Notes:
     How do you self identify (e.g. race, ethnicity, religion, sexual orientation)?
     

Payments ($30 per participant) should be mailed to:
East Ed
P.O. Box 57011
Washington, DC, 20037