Black & Latino Males
Conference

Registration

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   Please complete the registration form and submit it electronically by October 31, 2007. (note deadline date change)
 

   CONTACT INFORMATION:

Team Contact's Name:  

                    Institution:  

                      Address:  

                            City:                     State:    

                             Zip:             

           Email Address:               Phone:    




Team Members:
 
        Number of representatives in your team:     

        
          FACULTY and ADMINISTRATIVE Representatives:                         
        
                                     Name of Administrator:     

                               Title of Administrator:       
         
                               Gender (for rooming purposes only):      Male:        Female:

                               
                                     Name of Faculty member:  

                               Department:                            

                                     Gender (for rooming purposes only):      Male:         Female:                  

                              


        STUDENTS:

                                              Please list any dietary restrictions