2010 Civil Rights Conference

COST: The fee for the 2010 Civil Rights Conference is $50.00. The fee includes transportation during conference, meals, health & accident insurance, housing and program supplies.

Financial aid is available based on need. Please check the box to request information.

A $10 registration fee is due with the application. The remainder of the fee is due after you receive your acceptance letter.

Make checks payable to:
CCSJ-Civil Rights Conference
740 W. 5th St., Suite 210
Charlotte, NC 28202

Name (First & Last):
Address:
City:
State:
Zip:
Home Phone Number:
Cell Phone Number (optional):
Email Address:
High School:
Grade:
Gender:
Race:
Religion:
What are some things you would like to accomplish at your high school this year?
What issue are you most passionate about?
Do you require any specific accommodations for diet or accessibility? If so, please describe.
Parent/Guardian Name:
Parent/Guardian Signature:
Date:
Day Phone Number:
Financial Aid/Scholarship Requested?	Yes No