Social Justice Training Institute - Student Experience Application

Recipient of the 2005 Voice of Inclusion Medallion presented by the
American College Personnel Association

Student Experience Application

First Name
Last Name
Preferred Name (For nametag)
Mailing Address 1
Mailing Address 2
City
State
Zip Code
Email (that you check regularly)
Cell Phone
T-shirt Size
Emergency Contact
Phone
College/University
Class Standing in Fall 2008
Age (NOTE: Legal consent must be obtained for participants under the age of 18 years old)
SJTI Coach ’s Name
SJTI Coach ’s Email Address
Dietary Needs	Vegetarian Vegan Kosher Other, please specify:
What, if any, accommodations will you require to participate fully in the Institute (ASL interpreter, assistive/adaptive technology, etc.)?
Are you receiving outside funding or sponsorship (student government, grant, etc.)?	Yes No
What is your housing preference for the Institute?	please house me with a person who shares my gender identity no preference
Please tell us about your student involvement and activities, both on- and off-campus.
It is important to us that we select a diverse group of participants. Please share with us your identities in the following socio-cultural identity groups:
Racial/ethnic identity
Gender identity
Sexual Orientation
Socioeconomic Status (SES)
Nationality
Ableness/Disability
Religion/Spirituality
Any other socio-cultural identity group membership you feel is relevant
How did you hear about SJTI: The Student Experience?
Why do you want to attend SJTI: The Student Experience?
What kinds of experiences have you had that have helped you to understand diversity and social justice?
In what areas of diversity and social justice do you feel you most need to grow and learn?
How would you like to apply what you learn when you return to your home and college/university communities?

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