Make your own room reservations!
Be sure to identify yourself as part of the Kaleidoscope Leadership Institute for best room rates.
**Deadline October 31, 2002!**
Kaleidoscope Leadership Institute Application
Circle one: Ms./ Mrs./Dr.
NAME _________________________________________________
Last First Middle
SOCIAL SECURITY NUMBER_______-________-___________
ETHNICITY _____________________________________________
POSITION______________________________________________
PRESIDENT'S NAME _____________________________________
INSTITUTION____________________________________________
ADDRESS ____________________________________________
CITY/STATE/ZIP _________________________________________
OFFICE PHONE ________________________________________
E-MAIL ___________________________________________
FAX ____________________________________________
IMPORTANT NOTICE:
If you would like a roommate, please check here:
Double _____ Triple _____
Smoking _____ Non-Smoking _____
If you would you prefer vegetarian lunches please check here: _____
Make Checks or Purchase Orders payable to:
Kaleidoscope c/o Georgia Perimeter College
3251 Panthersville Road
Decatur, Georgia 30034
Attention: Felita T. Williams, Ph.D.
E-mail: Kaleidoscope@gpc.edu
Federal ID# : 58-1660133
To complete your registration, send the following to the above address: 1) Check or Purchase Order
2) Leadership Institute Application
3) Answers to questions
application (top) questions (below)
**Registration is not complete without the submission of your answers**
Please answer the following questions based on your experiences as a woman of color:
2. What workplace challenges are you experiencing?
3. What would you recommend to improve communications between other ethnic groups, including Euro- Americans?
4. Do you have a mentor? What type of mentor relationship would benefit you?
5. What would you like to gain from this leadership institute?
6. Where did you hear about Kaleidoscope?
Other comments:
Questions/concerns?
Contact:
Fax: 404-244-2399, ATTN: Felita T. Williams, Ph.D.
E-mail: Kaleidoscope@gpc.edu
Web page: www.gpc.edu/kaleidoscope