GROW Racial Justice Application for Thrive and Shift Cohorts

GROW Racial Justice Application for Thrive and Shift Cohorts

First Name

Last Name

Address Line 1

Address Line 2

City

Country

State

Provinces

State/Province

Postal Code

Email

Preferred Phone

Please select what type of phone this is

HomeWorkMobile

What pronouns do you use?

Please specify:

Age at start of program (June 2017):

What is your birthdate?

Month

Day

Year

Occupation

Please specify:

Did you participate in GROW Racial Justice 2016?

If yes, would you be interested in playing a leadership role at GROW Racial Justice 2017 or for the GROW Racial Justice track or workshops at General Assembly?

Please check which roles you feel most called and equipped to play:

Religious Affiliation

What is your religious affiliation? (Check all that apply)

All UUCSJ programs are open to people of any religious affiliation or no affiliation. Unitarian Universalism is a very inclusive faith. Our programs are designed to reflect the values and commitments of the UU faith while welcoming those of other faiths or lack thereof

Please specify:

In which region is your congregation located?

Which New England UU Congregation are you affiliated with?

If your congregation is not listed, select other

Which Mid-Atlantic UU Congregation are you affiliated with?

If your congregation is not listed, select other

Which Midwest UU Congregation are you affiliated with?

If your congregation is not listed, select other

Which South Atlantic UU Congregation are you affiliated with?

If your congregation is not listed, select other

Which South Non-Atlantic UU Congregation are you affiliated with?

If your congregation is not listed, select other

Which Mountain UU Congregation are you affiliated with?

If your congregation is not listed, select other

Which Pacific UU Congregation are you affiliated with?

If your congregation is not listed, select other

Which Canadian Congregation are you affiliated with?

If your congregation is not listed, select other

Which International Congregation are you affiliated with?

If your congregation is not listed, select other

Please specify:

Are you planning to attend General Assembly following GROW Racial Justice?

What faith and/or covenanted community (church, synagogue, sangha, etc.) are you part of? Please identify and/or describe. If none, type none.

If you are connected to a UU Congregation or other faith-based or spiritual community, please share briefly what roles you play there?

Identities: Please share a little about how you identify.

We will spend part of our time at GROW Racial Justice in racial identity cohorts. Please identify the cohort in which you would participate.

Thrive Cohort: for young adults of color (Black/African descent, Hispanic/Latinx, Middle Eastern, Asian/Pacific Islander, Indigenous/Native/American Indian, Multiracial)Shift Cohort: for white young adultsI'm not sure. I'd like to talk with someone about this.

Please share how you identify your Race/Ethnicity

Please specify:

What is your gender identity?

Please specify:

Is there anything else you'd like to tell us about identities that are important to you?

What is your current and past involvement with racial justice activism?

What is your current and past involvement with other social change movements?

What would you most like to gain from the GROW Racial Justice gathering? How do you hope to apply what you will gain from this experience?

In what ways have your identities (race, class, gender, ability, sexual orientation) had an impact on your spiritual and/or activist path?

Please tell us about any spiritual practices in which you engage (e.g. prayer, meditation, yoga, etc.) or other ways you ground and center yourself.

Please describe your general state of fitness, including any physical limitations, disabilities, allergies, dietary needs, etc.

Financial Information

The cost for this program is $350. Cost includes lodging, food and all programming but does not include transportation to and from the program.

Financial aid and travel subsidies are available based on need and are awarded on a first come first served basis. Would you like to apply for a reduced fee?

YesNo

Annual Household Income

Include child support, alimony, government assistance, etc.

Current value of cash, savings and checking accounts

Do you own your own home?

YesNo

Total value of your home

Total debt on your home

Is there any other information relevant to your financial situation that you would like to share?

We try to offer financial aid as much as possible. Would you consider donating? 100% of your pledge would go directly to the scholarship costs of participants who qualify for financial aid.

YesNo

Pledge Amount

Other amount:

References: Please give contact information for two people who can comment on your experience and abilities regarding this opportunity.

First Reference Name

Relationship to You

First Reference Phone

First Reference Email

Second Reference Name

Relationship to You

Second Reference Phone

Second Reference Email

Third Reference Name (Optional)

Relationship to You

Third Reference Phone

Third Reference Email

How did you hear about this UUCSJ Program?

*By signing this form, I confirm that to the best of my knowledge, the information provided in this application is true and correct.

Electronic signature

Today's Date

Month

Day

Year

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