2013 People of Color Conference (PoCC ) Adult Registration

Please photocopy this form and complete one for each adult attending. (For Group Discounts, send registrations together with one payment.)

HOW TO REGISTER

PARTICIPANT INFORMATION
PARTICIPANTS NAME (last, first, middle initial)

Williams, Leslie F.
GENDER IDENTITY (check one)

REGISTER ONLINE AT http://pocc.nais.org OR FAX THIS FORM TO (301) 694-5124 Registration forms must be submitted online or via fax. There is no mailed in registration. There is no on-site registration. For questions about registration, contact us at (866) 229-3691 or NAIS@experient-inc.com. REGISTRATION DEADLINE November 4, 2013. EARLY BIRD DEADLINE October 11, 2013. CANCELLATION POLICY Send registration can cellations in writing by November 4, 2013, to the fax number or email address above to receive a full refund less a $50 cancellation fee. No refunds are given after November 4. Cancellations cannot be made over the phone.
National Association of Independent Schools People of Color Conference December 57, 2013 National Harbor, MD

NAME AS IT SHOULD APPEAR ON BADGE

Leslie Williams

FEMALE

MALE

TRANSGENDER FEMALE

TRANSGENDER MALE

TITLE

Math Teacher x Teacher

Head of School Dean Board Member Diversity Counselor Assistant Admissions Director Other Assoc. Director

My position at my school is best described as:

SCHOOL/ORGANIZATION

Cary Academy

ADDRESS

1500 N. Harrison Ave. Cary, NC 27511 919-228-4584 919-388-0664 HOME TEL.

ON-SITE CELL

OFFICE TEL.

919-819-4889

FAX EMAIL

919-677-8670

leslie_williams@caryacademy.org x
12th IM AN SDLC CHAPERONE. 13th 14th 15th 16th

I DO NOT WANT MY NAME, SCHOOL, OR EMAIL ADDRESS LISTED ON THE PARTICIPANT LIST GIVEN TO ATTENDEES.

This will be my (check one)

1st 17th

x 2nd
18th

3rd 19th

4th 20th

5th 21st

6th 22nd

7th 23rd

8th 24th

9th 25th

10th

11th

26th PoCC

This is my schools first time attending the conference.

EMERGENCY CONTACT

George Benjamin Williams NAME TEL.

919-280-2101

The Affinity Group Work is critical to the success of PoCC/SDLC. While certainly optional, to plan for and comfortably accommodate these groups, it is important that each participant indicates the affinity group with which he or she identifies.

1. BLACK, AFRICAN HERITAGE, AFRO-CARIBBEAN HERITAGE, AFRICAN AMERICAN 2. LATINO/A HERITAGE, HISPANIC HERITAGE, LATINO/A OR HISPANIC AMERICAN 3. EAST ASIAN HERITAGE, SOUTHEAST ASIAN HERITAGE, SOUTH ASIAN HERITAGE, PACIFIC ISLANDER HERITAGE, EAST/SOUTHEAST/SOUTH ASIAN, ASIAN AMERICAN, HERITAGE FROM THE INDIAN SUB-CONTINENT x 5. WHITE, EUROPEAN HERITAGE, EUROPEAN AMERICAN 4. FIRST NATIONS HERITAGE, INDIGENOUS AND ABORIGINAL PEOPLE, NATIVE AMERICAN 6. GREATER MIDDLE EASTERN HERITAGE, ARAB HERITAGE, WEST ASIAN HERITAGE, MIDDLE EASTERN OR ARAB OR WEST ASIAN AMERICAN 7. MULTIRACIAL HERITAGE, MULTIRACIAL AMERICAN 8. TRANSRACIALLY ADOPTED 9. INTERNATIONALCITIZENS FROM COUNTRIES OUTSIDE OF THE U.S., RECENT ARRIVALS TO THE UNITED STATES
If different from above, please indicate the affinity group session you wish to attend. DIETARY NEEDS: PHYSICAL VEGETARIAN KOSHER SHELLFISH ALLERGIES DIABETIC VEGAN GLUTEN-FREE I AM ALLERGIC TO:

Please check here if you require special accommodations to participate. Fax a written description of your needs to PoCC/SDLC, NAIS, (888) 316-3862.

Will you need to secure housing?

x Yes

No If no, why:

I am a local resident.

I am sharing a room with another attendee.

No overnight stay required.

CONFERENCE REGISTRATION AND EVENTS

REGISTRATION RATES
MEMBER INDIVIDUAL for NAIS, VAIS, AIMS, IE, and SAES members x $620 Early Bird by October 11 $700 Standard by November 4 MEMBER GROUP (5 OR MORE ADULTS
FROM SAME SCHOOL, PAYMENT RECEIVED AT SAME TIME)

SPECIAL EVENTS
NONMEMBER INDIVIDUAL $900 Early Bird by October 11 $980 Standard by November 4 WORKSHOP PRESENTERS $520 Early Bird by October 11 $600 Standard by November 4 AFFINITY GROUP FACILITATORS $520 Early Bird by October 11 $600 Standard by November 4 COMMUNITY SERVICE OPPORTUNITIES $35 Wed., December 4, 1:003:00 PM Clean the World Foundation LEADERSHIP SEMINAR FOR PEOPLE OF COLOR AND WOMEN $250 Wed., December 4, 9:00 AM5:00 PM SCHOOL VISIT $50 (choose one school) Wed., December 4, 9:00 AM1:00 PM

$595 Early Bird by October 11 $680 Standard by November 4

Episcopal High School Green Acres School

Madeira School St. Andrews Episcopal School

DISCOUNT CODE: If you were given a discount code for registration, please insert it here.

TOTAL FEES ENCLOSED = $

PAYMENT
VISA AMEX MC CARD #

CHECK (PAYABLE TO NAIS)

CHARGE MY CREDIT CARD.

EXP. DATE

DAYTIME TEL.

NAME ON CARD

SIGNATURE

All participants are welcome to attend. NAIS has an institutional commitment to the principles of diversity. In that spirit, NAIS does not discriminate in violation of the law on the basis of race, religion, creed, color, sexual orientation, age, physical challenge, national origin, gender, or any other characteristic.

Register online at http://pocc.nais.org. Early Bird Deadline: October 11. Registration Deadline: November 4.