2004 National Conference Registration Form

Instructions:

1. Please take a moment to complete the registration form below. Note that although only a few of the fields are absolutely required, you are strongly encouraged to complete all of the fields that are relevant to you. Please note that your contact information will be shared with the other conference participants.

2. Once you have completed the form, click on the Review button at the bottom of the page. If you missed a required field, an error message will appear below these instructions. If this happens, make the appropriate changes and re-click the Review button.

3. Once all required fields have been filled in and you have clicked on Review, a Submit button will appear at the bottom of the page. Re-check your responses if you'd like to, then click on the Submit button to submit your registration form and proceed to your payment options. Important: if you do not click on the Submit button, we will not receive your registration.

--

General Information:
Salutation (Mr., Ms., Dr., Rev., etc.):
First Name: ??(required)
Middle Name or Initial (optional):
Last Name: ??(required)
Suffix (Jr., Ph.D., etc.):
Name Tag:
How would you like your name to appear on your name tag? Please include your surname.

??(required)
Contact information:
Organization or School:
Your Title/Position:
Address (line 1):
Address (line 2):
City:
State or Province:
Country (if not U.S.):
Zip Code or Country Code:
Daytime Phone: ??(required)
Alternative Phone:
Email Address: ??(required)
Website Address:
Demographic Information:
Diversity among conference participants and presenters is very important to us.
The following information will help us determine how we are doing on our goals.
What is your gender?
What is your race/ethnicity? (Latino, white, etc.)
What is your age? under 18 ? 18 - 25 ? 26 - 35 ? 36 - 45 ? 46 - 55 ? 56 - 65 ? over 65
What is your political ideology? (Republican, progressive, etc.)
Special Needs:
Do you have any special needs that we should be aware of in order to make sure you are comfortable and are able to fully participate?
Examples would be wheelchair assistance, a requirement of vegetarian or kosher food, etc.
The Conference from October 23 to 25, 2004:
Will you be participating in the conference?
(Only select "no" if you choose not to participate in the main conference and only plan to attend a post-conference training.)
?Yes? ?No Registration Fee: $450 -- Please note that the registration fee covers most meals, but does not cover your lodging.
Post-Conference Trainings on October 26, 2004:
If you wish to attend a post conference training, select one training below. For more information about each training, look over the post-conference training descriptions (this will open in a new browser window).
I will not be attending a post-conference training.
Training A??$150 Organizing and Moderating Sustained Dialogue to Transform Racial and Ethnic Conflicts in Communities, Corporations and Campuses (Harold Saunders and Priya N. Parker)
Training B ??$150 Convening and Moderating National Issues Forums (Senator Les Ihara and Taylor Willingham)
Training C??$150 Introduction to Spiral Dynamics has been cancelled and replaced with a weekend workshop.
Training D??$150 Using Study Circles to Facilitate Community Dialogue and Support Citizen Action (Sally Campbell and Gloria Mengual)
Training E??$150 Dialogue to Reconciliation Using Nonviolent Communication (Miki Kashtan)
Training F??$150 An Introduction to Dynamic Facilitation, Choice-creating, and the Wisdom Council (Jim and Jean Rough)
Training G??$150 Using Dialogue to Influence Decision Making in Your Organization has been cancelled.
Training H??$150 Inquiry as Intervention (Corky Becker)
Training I??$150 Addressing the Campus Climate for Diversity: Promoting Positive Intergroup Relations using Structured Intergroup Interaction Initiatives (Jesus Trevino, Lamont Sellers and Niki Latino)
Training J??$100 Planning, Facilitating, and Evaluating a City-wide Public Dialogue Process (Kim and Barnett Pearce)
Training K??$100 Experiencing Bohmian Dialogue (Lee Nichol and Ray Seigfried)
Training L??FREE Deliberating Public Issues Online: Using Democracy Lab in your Classes and for Student Civic Leadership Team Development (Jim Knauer)
Donations to the Conference Scholarship Fund:
Please consider making an additional contribution to the conference if you can. Your contribution to our scholarship program will help cover the expenses of those who may not otherwise be able to attend. Contributors to our scholarship fund will be listed in the conference program and on the website.
$200 Donation ??$200
$100 Donation ??$100
$50 Donation ??$50
Thank You:

We are thrilled that you have decided to attend the 2004 National Conference on Dialogue & Deliberation. We look forward to seeing you in October!

Please review or submit your registration by clicking the box below.
Preview your responses before submission.
Review your submission:

--

Return to the top of this page...