Civil Rights Learning Journey Registration - Institute for Educational Leadership

Civil Rights Learning Journey Registration

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Please use the following form to register for the November 2018 Civil Rights Learning Journey.

Civil Rights Bus Tour Registration
First Name *
Middle Name
Last Name *
Email Address *
Cell Phone Number *		Home Phone Number
Home Address Line 1 *
Home Address Line 2
Home City *		Home State *
Home Zip/Postal Code *
Professional Title *		Organization *
Work Address Line 1 *
Work address Line 2
City *		State *
Zip/Postal Code *
How did you hear about this bus tour?
Are you a member of the National AfterSchool Association?You are not required to be a member to participate.
Are you an alum of EPFP? *You are not required to be an alumnus/a of EPFP to participate in the Civil Rights Bus Tour, but in the event that interest exceeds capacity, preference will be given to EPFP alumni.
If you are an EPFP alum, please indicate your state affiliation at the time of your EPFP year
Departure City and State *Please indicate your preferred U.S. departure city for Jackson, MS.
Describe your current organization & role *Describe the work of your organization and your role within it.	500 of 500 characters remaining
What do you hope to gain from the Civil Rights Bus Tour?

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