Form

An Unfinished Conversation with Lee Mun Wah

Event Registration
This is a FREE event but registration is required for all sessions.

Date: February 12, 2013 (sessions from 9:00 a.m. - 10:00 p.m.)
Location: UMass Amherst Student Union Ballroom
Parking: Discounted parking (no more than $5/day) is available in the parking garage. Free parking is also available in Lot 12

There are a limited number of registration slots available per institution. If the number of registration slots are full, you will be notified and placed on a waiting list. Upon the completion of the registration, you will be asked to complete a participant questionnaire. Thank you in advance.

If you have any questions, please e-mail 5clmwevent@gmail.com
Event information can also be found here: Lee Mun Wah event
Full Name*
First Name Last Name
E-mail*
What is your affiliation?

Amherst College Hampshire College Mt. Holyoke College Smith College University of Massachusetts Amherst Five Colleges, Inc. Prefer not to answer Other
Please indicate your affiliation and how you heard about this event:
I would like to attend the following sessions:

Keynote: "What Stands Between Us" 9am - 10am (open to all) Film Showing & Diversity Dialogue: "If These Halls Could Talk" 7pm - 10pm (open to all)
What is your role at Amherst College?

Administration Department Head Faculty: Lecturer Faculty: Tenured Faculty: Visiting Professor/Lecturer Front Line Staff Staff Supervisor Trustee- Appointed Supervisor Student Prefer not to answer
What is your role at Hampshire College?

Adjunct Faculty Administration Department Head Faculty: Tenured Faculty: Tenure-track Faculty: Visiting Professor/Lecturer Front Line Staff Staff Supervisor Student Prefer not to answer
What is your role at Mt. Holyoke College?

Administration Exempt Staff Faculty: Lecturer Faculty: Tenured Faculty: Tenure-Track Faculty: Visiting Professor Non-exempt staff Student Prefer not to answer
What is your role at Smith College?

Administration (e.g. senior staff not in senior admin.) Administration Support (other staff that is non-union Course Support (e.g. lab technicians, post-doc fellows) Faculty Senior Administration Service Staff Graduate Student Undergraduate Student Prefer not to answer
What is your role at UMass Amherst

Adjunct Faculty Exempt (Professional) Staff Dean Department Head Director Non-exempt (Classified) Staff Senior Administrator Tenured Faculty Tenure-Track Faculty Visiting Professor/Lecturer Graduate Student Graduate Student Employee Undergraduate Student Prefer not to answer
I would like to attend the following event sessions:

Keynote: "What Stands Between Us" 9am - 10am (open to all) Student session: A Cross Gender/Race Conversation" 10am -12pm (open to undergraduate and graduate students) Faculty/staff session: "Diversity Conversations in the Classroom and Workplace" 1pm - 5pm (open to faculty, staff, and graduate employees) Film Showing & Diversity Dialogue: "If These Halls Could Talk" 7pm - 10pm (open to all)
Are you interested in being contacted to participate in future dialogue opportunities about diversity topics?

Yes No
Additional Comments:
Should be Empty:

An Unfinished Conversation with Lee Mun Wah