2020-2021 Cohort Application
RequiredRequired Question(s)
Required 1.
Please enter the information indicated below.

First Name:
Last Name:
Email Address:
emailaddress@xyz.com
Address 1:
City:
State/Province
(US/Canada):
Postal Code:
Cell Phone:

Required 2.

I identify as:

Black/African American
White/Caucasian
Latino
Asian American/Pacific Islander
Native American
African
Prefer not to answer
Other  
Required 3.

My age range is

21 - 35
36 - 45
46 - 55
56 - 65
66 - 75
76 and above
Required 4.

I identify as:

Male
Female
Non-binary
Prefer not to answer
Required 5.
You are applying to be a part of a group of individuals committed to learning more about bias and structural racism.  Have you ever attended similar training session on this topic?
Yes
No
6.

If yes, please describe.

 

350 characters left.
Required 7.

Why are you choosing to participate in this dialogue series?

 

350 characters left.
Required 8.

Are you willing to commit to participating in difficult discussions with an open mind?

Yes
No
Maybe
Required 9.

Would you say that most of your interactions are with people who you identify as similar to you?

 Vast majority Mostly Some Very Few  
Gender  
Race  
Ethnicity  
Sexual Orientation  
Religion  
Geographic/Neighborho-
od
 
Ideology  
  • Comment:

  • 500 characters left.
Required 10.

Please complete the following sentence. This series will have been worth my time if after completion I...

 

350 characters left.
Required 11.

The sessions are held mostly on the second Tuesday of each month, November 2020 through June 2021.  If selected, I am able and committed to attending ALL sessions.

Yes
No
Required 12.

I understand that if I miss more than two sessions, I will be removed from the group.

Yes
No
Required 13.

Due to COVID-19 pandemic, I understand the sessions will be hosted virtually and that I am responsible for having a reliable, secure internet connection to attend sessions. Technical support from the facilitator is limited to the presentation of and access to session content.

Yes
No
  • Comment:

  • 500 characters left.
Required 14.
I understand, if selected, there is a nonrefundable cohort fee. 

Yes
No
Other  
Required 15.
Initial here. 
 

50 characters left.