For each attendee, please provide the following information:



Preferred Pronouns
Title
First Name*
Last Name*
Suffix
Email Address*
Organizational
Position
Organizational Unit/Department
Organization

Are you participating alone or as part of a team?*
 Individual   Team
 
If you are part of a team, please list your fellow team members, if known:


Address*
Address2
City*
County*
State/Province* 
Zip/Postal Code*
Country*

Phone Number*

Demographic Information 
Please check any applicable boxes:
(This information is for internal purposes and no personally identifying information will ever be shared with any third party.)

Race/Ethnicity
 White/Caucasian   
 Black/African-American   
 Asian-American/Pacific Islander   
 Native American/First Peoples   
 ispanic/Latino   
 Multiracial/Multiple Heritage   
 I prefer not to answer
 
Sex/Gender Orientation and Identity
 Female   
 Male   
 Intersex   
 Agender - as a sex/gender identity   
 Other Sex/Gender Identity   
 Heterosexual/Straight   
 Homosexual/Gay/Lesbian   
 Bisexual/Pansexual   
 Asexual - as a sex/gender orientation   
 Transsexual/Transgender   
 Genderqueer/Gender-fluid   
 Other Sex/Gender Orientation
 
If you have a disability which may require accommodation, please provide any details you feel are necessary, so that we can do our best to ensure your comfort:

Special Dietary Considerations

History
Have you participated in the Vermont Vision for a Multicultural Future Conference in prior years?*
 New Participant
 2018   
 2017   
 2016   
 2015   
 2014   
 2013   
 2012

Have you previously facilitated a workshop at the Vermont Vision for a Multicultural Future Conference? Please list workshop topics you have facilitated:


Notes
Please include any additional information or details you feel are relevant to your registration: