L.E.A.D. CENTER > Social Justice > Safe Space > Workshops > Registration Form Student L.E.A.D. Center
   

Safe Space Registration Form

In order for us to prepare for the training session, please provide us with the following
information. The information will be used for tracking purposes only.
 
Affiliation with Chapman University: Faculty
Staff
RA
Student
Greek
Other:  
Students are asked to complete section "A" of this form. (Please note: Students who are also
staff or faculty are asked to complete section "B" of this form.)
A. Student:
List your Campus involvement:
Name:
Major:
Class: Freshman
Sophomore
Junior
Senior
Graduate
E-mail:
B. Staff and Faculty members:
Name:
Department:
Building:
Office Phone:
E-mail:
 
EVERYONE completes:
How did you hear about Safe Space Program?
What do you expect to gain from this workshop?
Please provide us with one question you would like answered or information you would like addressed:
Rate your knowledge
of the LGBT community:		 (1 = no knowledge ...5 = very knowledgeable)
Please check one in each category:
Gender: Man
Woman
Transgender
Gender Variant
GenderQueer
Other
No Response
Sexual Orientation: Heterosexual
Lesbian
Gay
Bisexual
Queer
Questioning
Pansexual
Other
No Response
Race/Ethnicity: African American/Black
Asian American
Caucasian/White/Non-Hispanic
American Indian
Hispanic/Latino/a
Bi-/Multi-racial
Other
No Response
Workshop I would
like to attend: 		Jan. 16 & 23, 10am-12:30pm (Train the Trainers; Safe Space Training Workshop is a Prerequisite)
Wed., Feb. 11 at 7pm (Safe Space Training Workshop)
Tues., Mar. 3 at 7pm (Safe Space Training Workshop)
Fri., April 17 at 10am (Safe Space Training Workshop)
Fri., May 8 at 10am (Transgender Training Workshop)
 
**You will be e-mailed your confirmation for your preferred workshop**
Space is limited and training sessions will be filled on a first-come, first-served basis.
For more information please contact Safe Space at safespace@chapman.edu

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