MLK Trip Registration Form

	2009 Civil Rights Immersion Trip Lawence, KS & Haskell Indian Nations University January 15-18, 2009
	Reservation Form

Please complete the following reservation form. If you have any questions not answered on the information page contact Chloë Coenen (ccoenen / 856-1304) or Barry Magee (bmagee / 855-2410).

CONTACT INFORMATION

First name: Last name:

Phone - Best: Phone - Alt.:

Complete Email Address:

Emergency Contact (Name/Phone):

BACKGROUND INFORMATION

Because the trip is supported by many different groups and offices some of this information helps us to create for them a picture of our diverse group of participants.

Affiliation:
Do you live in a Residence Hall or Off Campus? Select:
Racial/Ethnic Identity:

Gender Identity:

School/Dept:
The school/dept. you are enrolled in as a major or if you are a staff member you work for.

TRIP RELATED INFORMATION

The following information helps us in planning the best experience we can for you.
Do you have a roommate request?:
      You will be rooming with 3 other people.

Yes No    Have you been to Lawrence, KS before?
Yes No    Have you been on a Civil Rights trip with the CommUNITY Education Program in the past?
Yes No    Have you ever visited a reservation or a tribal college?

How did you hear about this trip?
Word of Mouth
Email Distribution List
CommUNITY Educator
Campus MLK Day Website
Other

Do you belong to any student organization on campus? If so, which one(s):

What would you like to get out of this trip?:

AGREEMENTS and DETAILS

To complete this reservation and guarantee a seat on the bus I understand that I must also submit the $25.00 participation fee to Barry Magee at 801 N. Jordan, RM 221 (cash or checks accepted; 8 - 5 p.m.).

The trip organizers will arrange to pay for the bus, the hotel room (quad occupancy), and admission to scheduled sites. All food and incidentals are my responsibility.

I understand that I am responsible for my behavior while on the trip and that I am responsible for abiding by all University regulations and state laws.

It will be my responsibility to stick to the printed and announced schedule. If I miss the bus at any point it will be my responsibility to find and pay for alternative transportation. If I do not participate in scheduled activities I could be asked to leave the group and return to Bloomington at my own expense.

As a part of this trip I will attend a scheduled meeting prior to leave on the bus. As a participant I will also be invited and encouraged to attend a retreat on campus following the trip on February 6th.

I accept these terms: Yes No

SUBMIT FORM

THANK YOU. The CommUNITY Education Program looks forward to your participation on the trip!