Application Form

Within your comfort level, please respond to the following:

Name:
Name for nametag:
Position / Title:
Describe your responsibilities:
Name of Institution or place of work:
Work Address (snail mail):
City, State & Zip Code:	,
Cell Phone:
Work Phone:
Work Fax:
Work E-mail:
This application is for SJTI, Springfield, MA – June 11 – 15, 2012.
Have you applied to SJTI before?:	Yes No
Is anyone else applying from your institution?:	Yes No Please list names:
Would you like to be considered for a $100 need-based scholarship?	Yes No Why?
How do you identify Racially/Ethnically? (If biracial/multiracial, please include all racial groups that comprise your heritage):
Gender:
Age:
Sexual Orientation:
Religion / Spirituality:
Socioeconomic class of Origin:
Nationality:
Ability / Disability:
List any other social identity group memberships that you feel are relevant to your work as a diversity trainer or practitioner on issues of race & racism: Describe your experience as a trainer of diversity seminars or practitioner exploring issues of race & racism (how long; target populations; general formats for sessions; etc..) Write about the areas you need some work on and/or issues you bump into as a trainer or practitioner on issues of race & racism. Also, comment on the skills and competencies you hope to learn during the institute. How did you hear about SJTI?