Retention Through Resiliency

Application Form

---Please print this form and fax to (307) 755-5532---

Position/Title ___________________________________________ Years in TRIO __________

Project(s): ( )SSS, ( )UB, ( )VUB, ( )MSUB, ( )EOC, ( )TS, ( )McNair

Institution/Agency______________________________________________________________

Address_____________________________________________________________________

City/State/Zip_________________________________________________________________

ERROR MSGTelephone (_____)_________________________ Fax (_____)_________________________

E-Mail__________________________________________

 

Please indicate your preferred training site:

Boston, MA February 2-5, 2000

Austin, TX March 9-11, 2000

Long Beach, CA April 27-29, 2000

Please indicate your ethnic/racial background:

____American Indian ____Asian American____Black/African American ____Pacific Islander

____Latino/Hispanic/Chicano/Mexican American ____Caucasian

____Other (Please Specify)______________________________________________________

ASPIRE Training Institute does not discriminate on the basis of race, sex, religion, disability or national origin. The above information is gathered for reporting purposes only.

Please list any special accommodation/dietary needs: _________________________________

I would like to have my name added to a list of participants who want to share a hotel room in order of offset costs. ____Yes, add my name and send me a list ____ No

Would you like to register for the RTR listserv? ________Yes _______No

If you are not the director of the project, please have your director approve your application:

Director’s Name

___

Director’s Signature