Dialogue on Race

Participant Application

We're glad you are interested in DOR. Please print this application and complete it by hand. Please deliver it or mail it to the Counseling & Student Development Center, Campus Life Building 200, DeKalb, IL 60115.  A staff member will contact you to schedule an interview.  We are looking forward to talking with you about this opportunity!

Name: ____________________________________________________

Local Phone: _______________________________________________

Local Address: _____________________________________________

Most frequently used e-mail address:

_________________________________________________________

Your ethnicity/race: __________________________________________

Your year in school: __________________________________________

How did you hear about Dialogue on Race?

_________________________________________________________

When we contact you, we will ask for the following additional information:

1.         What motivates you to get involved with Dialogue on Race?

2.         What type of experience do you have with this type of activity?  (None is required.)