IRC of CNY

InterReligious Council of CNY - 3049 E. Genesee St. - Syracuse, NY 13224 - Tel: 315.449.3552 - Fax: 315.449.3103

Community Wide Dialogue

End Racism, Improve Race Relations, Promote Racial Healing

Registration Form for Dialogue Circles

If you prefer a hard copy of this form, please download it, fill it out and send it back to the
InterReligious Council, 3049 E. Genesee Street, Syracuse, NY 13224
or fax it to 449-3103.
Please call (315) 449-3552 ext. 119 or e-mail cwd1@irccny.org with questions.


 

Name:

* Home Phone: *

Address:

Work Phone:  

City:

Email: *

State:

Fax:  

Zip Code:

     
 


Circles meet 6 consequtive weeks once a week for two hours. When 12-15 individuals have requested a time period, you will be contacted regarding the location and your availability.

Please check the time that best fits your schedule. If you can meet at more than one time, check all for which you are available. This will increase our ability to place you in a circle quickly.
 

Morning


Evening  

Midday


Other  

Afternoon


Specify:

Help! I want to participate but none of these options works for me! Please call.

   

I have special circumstances which are:

  
 


To make the Dialogue Circles succeed, it is important to make them racially and ethnically diverse.  It is therefore important for us to know your race and ethnicity.  Please answer the following questions.
 

Race:

     

Age:

     

Gender:

     


  

 

1. Facing Racism - A Collaborative Project of WCNY-TV and Community Wide Dialogue to End Racism of the InterReligious Council of Central New York

_______________

2. Duck Race To End Racism 2005
DR2006

_______________

3. Fabius Pompey and Ed Smith Elementary Schools Exchange Project

_______________

4. Nottingham & Fayetteville-Manlius High Schools Exchange Project

© 2001 - 2006 InterReligious Council of Central New York