Name:

Preferred email address:

Local mailing address:

City:   State:   Zip Code:

Preferred phone #:   Home / Cell:  Home   Cell   Office

Status:
Faculty
Staff
Undergraduate
Graduate

Which workshop date are you able to attend?

Wednesday, May 9, 2012 - 3:00pm - 5:00pm

Note: To attend the Safe Space Member training participants must have already
completed the Safe Space Foundations workshop. If you register and have not completed the Foundations Training you will be automatically deregistered.

Enter any other comments here: