Examining Unconscious Bias Registration Form

Important Information

Please note: Attendance is required at all sessions, as each session builds upon the previous. Please ensure you are able to attend all of the virtual program sessions before you apply.

Fall 2022 Program Dates: October 4 & 5. The sessions will be held in-person and run from 8:30 a.m. - 4:30 p.m. CST

Registration Type

Quantity:

*Note: If you are purchasing a group of 10 or multiple (2-9) individual registrations at once, we will be in touch to collect your participant names and details. They will be due by September 13.

First Name

Last Name:

Title (i.e. Director of Marketing):

E-mail:

Company Name:

Business Address:

Business City:

Business State

Business ZIP Code

Business Phone:

Home ZIP Code:

Cell Phone:

What is your preferred pronoun?

I identify my ethnicity as:

AsianBlack/African AmericanCaucasianHispanic/LatinxNative AmericanPacific IslanderMiddle EasternPrefer not to shareOther

INvoice Contact - Who shall we send the invoice to for THE program registration fee? Contact tracy@icanleaders.org for alternative payment option.

First Name

Last Name

Title:

Email:

Have you ever attended an ICAN program?:

Please list ICAN programs or events you've attended:

Any Additional Information:

If you DO NOT wish for your pictures or comments to be used in ICAN promotional materials please check the box.

I UNDERSTAND THAT ALL INFORMATION SUBMITTED WILL BE USED BY THE ICAN, INC. OFFICE AND FACULTY ONLY. FACILITATORS PLEDGE ABSOLUTE CONFIDENTIALITY REGARDING INFORMATION CONTAINED IN ALL PROGRAM ENGAGEMENTS.

I UNDERSTAND THAT SUBMISSION OF THIS COMPLETED REGISTRATION INDICATES THAT BOTH MY EMPLOYER AND I HAVE REVIEWED AND ACCEPT THE PROGRAM'S REQUIRED COMMITMENT OF TIME AND FINANCIAL RESOURCES. TUITION IS NONREFUNDABLE. SUBMISSION OF A COMPLETED REGISTRATION INDICATES YOU ACCEPT THESE REFUND TERMS.

I accept these terms

Please note: Once your registration is received, you will receive an email confirmation from ICAN. IF YOU DO NOT RECEIVE AN EMAIL WITHIN THE NEXT BUSINESS WEEK, please contact ICAN at ican@icanleaders.org to confirm receipt of your registration.

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Contact Information