mosaic

MOSAIC 2009 REGISTRATION PAGE

Registration for MOSAIC 2010 is now open !

HURRY Deadline for registration is

MONDAY, February 15th!

Spaces are going fast!

1. First Name
2. Last Name
3. Name as you would like it to appear on your nametag
4. The best email address to reach you at
5. The best phone number to reach you at ( ) - -
6. How many total semesters have you been at UMD (including this one)?
7. What is your enrollment status at the University? Undergraduate Student
Graduate Student
8. Will you be sponsored by a department/program/organization? Yes
No
9. If yes, what is the name of the sponsoring department/program/organization?
10. Sponsor contact name

11. Sponsor contact email address

12. Do you have any food restrictions?

13. Do you have any special needs or accommodations that we should know about?

 

14. University ID number
(the number on the front of your UMDCP ID card, NOT your social security number)

 
15. What is your major?
16. What is your race(s) and/or ethnicity (ethnities)? (optional)
17. What is your gender? (optional)
18. What is your sexual orientation? (optional)
19. What is your religious and/or spiritual orientation? (optional)
20. What is your nationality? (optional)
21. How did you learn about the MOSAIC retreat?
22. Why would you like to attend the MOSAIC retreat?
(do not worry, you do not need to write a thesis here a few sentences will suffice)
23. What do you hope to gain from the MOSAIC retreat?
(do not worry, you do not need to write a thesis here a few sentences will suffice)
24. What is your definition of diversity?
(do not worry, you do not need to write a thesis here a few sentences will suffice)
25. What is your definition of Leadership?
(do not worry, you do not need to write a thesis here a few sentences will suffice)
26. How do you see diversity and leadership related?
(do not worry, you do not need to write a thesis here a few sentences will suffice)
27. At this point in your life, which social identities do you identify with or think about the most? (optional)

[for the purposes of answering this question, social identities include race, ethnicity, gender, sexual orientation, (dis)ability, social class, religious/spiritual affiliations or orientations, nationality]

(Again, do not worry, you do not need to write a thesis here a few sentences will suffice)
28. What kinds of student or other kinds of groups, organizations or programs have you been a part of?
29. Have you played a leadership role in any of these involvements? If so, how?

30. Please read the following statement and initial your name in the text box to the right.

Cancellation Policy:

I understand that by signing up, I am authorizing the Adele H. Stamp Student Union- Center for Campus Life to debit my student account in the amount of $35 should I sign up to attend the MOSAIC retreat and either cancel after the deadline or not attend the retreat.

Note: We are committed to making the MOSAIC retreat as accessible for all students, and will work with you in any way possible to ensure accessibility. Should you have any questions regarding general or specific accomidations, please feel free to contact Craig Alimo at 4-1391 or via email at calimo@umd.edu