Registration

Contact Person Information

         Last Name:              First Name:

     School Name: Organization Name:

Mailling Address:

                    City                          State   AL AK AS AZ AR CA CO CT DE DC FM FL GA GU ID HI IL IN IA KS KY LA ME MH MD MA MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SV SD TN TX UT VT VI VA WA WV WI WY Zip Code

              Phone: ( ) -                   E-Mail:

Please select the number of participant(s) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

Please Check this Box if you are a Student Requesting a Fee Waiver

Payment options (All checks should be made out to University Auxiliary Services, Inc)

Registration Fee $20 (Student waivers available)

Check #

Purchase Order #

Diversity Committee
School of Social Welfare
University at Albany
Attn: Dikla Madera
1400 Washington Ave.
Albany, N.Y. 12222

Write your comments or concerns here.

After submiting the form please print or save the registration recipt for your own records.

Please Note: This order form does not confirm registration. You must also pay the $20 registration fee. Registration will be completed the day of the conference by checking a list of the people who have paid. On-site registration will also be available but it does not guarantee the availability of lunch. Registration fees will be waived for students at their request but you must pre-register and request such a waiver by indicating your student status on the form.