Creating New Legacies Inspired by the Dream

January 30, 2010, 1:00pm – 4:00pm

Tougaloo College, Mississippi

Event Registration

This event is free and open to the public. Registering will ensure that you get a seat.

We will use your contact information to announce any changes related to the event and to follow up after the event with an opportunity for your input. Birth year and ethnicity are for our records so we can track age and ethnic diversity at our events. We will not share your names and contact information with other parties.

This form allows for up to five registrants. Please enter each person’s information individually. If more than five are in your party, please submit an additional registration form.

Registrant 1
Name *
Organizational Affiliation

Please write "none" or "personal interest" if you are not affiliated with an organization or group.
E-mail *
Phone - (###) - ### ####
Year of Birth
Ethnic Background
Indicate how you self-identify (if "Other" is chosen above)
Registrant 2
Name
Organizational Affiliation

Please write "none" or "personal interest" if you are not affiliated with an organization or group.
E-mail
Phone - (###) - ### ####
Year of Birth
Ethnic Background
Indicate how you self-identify (if "Other" is chosen above)
Registrant 3
Name
Organizational Affiliation

Please write "none" or "personal interest" if you are not affiliated with an organization or group.
E-mail
Phone - (###) - ### ####
Year of Birth
Ethnic Background
Indicate how you self-identify (if "Other" is chosen above)
Registrant 4
Name
Organizational Affiliation

Please write "none" or "personal interest" if you are not affiliated with an organization or group.
E-mail
Phone - (###) - ### ####
Year of Birth
Ethnic Background
Indicate how you self-identify (if "Other" is chosen above)
Registrant 5
Name
Organizational Affiliation

Please write "none" or "personal interest" if you are not affiliated with an organization or group.
E-mail
Phone - (###) - ### ####
Year of Birth
Ethnic Background
Indicate how you self-identify (if "Other" is chosen above)
Contact Information

Coming to the Table
Eastern Mennonite University
Harrisonburg, VA 22802
USA

Telephone: 1-877-540-CTTT (2888)
Fax: 540-432-4449
e-mail: cttt@emu.edu

Creating New Legacies Inspired by the Dream

Creating New Legacies Inspired by the Dream

Registrant 1

Registrant 2

Registrant 3

Registrant 4

Registrant 5

Contact Information