Intergroup Dialogue Application Form

Thank you for your interest in intergroup dialogue. Please note that applications will be reviewed and students will be notified of their placement as soon as possible. Students placed into credit bearing dialouges may enroll via WebReg after notification of placement.

Personal Information

• First Name:
• Last Name:
• Student ID number:
• Year in School:

  Freshman
  Sophomore
  Junior
  Senior
  Other
  
• If other, please specify:
• College:
• Age:
• Major:
• Second major:

• Check here if you are willing to be placed in an alternate dialogue if CAT124 Intergroup Dialogue on Race/Ethnicity is full. The topic of the alternate dialogue may be race/ethnicity or gender.

• Have you ever participated in an intergroup dialogue?

  Yes No
  
  If yes, specify:
  
• Briefly describe your interest in taking a course on intergroup dialogue - including a description of any previous course experience or other background information that you feel is important for instructors to know.

CONTACT INFORMATION

• E-mail Address:
• Local Phone:
• Local Address:

  Street:
  City:
  Zip Code:

• Permanent Address:

  Street:
  City:
  State:
  Zip:
• What is the best way to reach you?

  e-mail phone mail
  

DEMOGRAPHIC BACKGROUND AND IDENTITIES

To assist us in creating a diverse and well-balanced dialogue, we would appreciate your voluntary response to the following items. Your responses to these questions will be kept confidential.

Please choose the option for each category that best describes how you identify yourself, along with any additional details where there is space provided.

• 1a. Your racial/ethnic description identification (Please mark all that apply):

  African American or Black:
       (Specify national origin):
  Asian American or Asian:
       (Specify national origin):
  Latina(o)/_Hispanic_American:
       (Specify national origin):
  Native American/American Indian/Alaskan Native:
       (Specify national origin):
  Arab American or Arab:
       (Specify national origin):
  White/European American:
       (Specify national origin):
  Other
       (please specify racial/ethnic identification):
• 1b. If you marked more than one racial/ethnic identity group above, which is one do you identify with the most?

  African American or Black:
  Asian American or Asian:
  Latina(o)/ Hispanic American:
  Native American/American Indian/Alaskan Native:
  Arab American or Arab:
  White/European American:
  Other ()
  
• 2. Gender:

  Female Male Transgender
• 3. Sexual Orientation:

  Bisexual Gay Heterosexual
  Lesbian Questioning
• 4. Current Religious Preference: Select... Christian Jewish LDS (Mormon) Hindu Islamic Buddhist Sikh Other religion Athiest Agnostic Other non-religious
  
  If other, please specify:
• 5. Citizenship status:

  U.S. Citizen Permanent U.S. Resident Non U.S. Resident
• 6. Disability, if any:
• 7. Primary regional area where you grew up (please check all that apply):

  Urban Suburban Rural
  Other (Please Specify regional area)
• 8. Please list any other group memberships or social identities that are important to you:
  
• 9. How did you hear about the Intergroup Dialogue?