Syracuse University
CARE Intergroup Dialogue Application Form

RESIDENCE HALLS

Fall 2007
       
Thank you for your interest in intergroup dialogue! CARE dialogues are open to both residential and non-residential students. Fall semester CARE dialogues will start during the week of  October1 and will be completed by November11.

If you are interested in participating, please complete and submit the following application. Confirmation will be sent electronically the week of September 24 and will include dates, names of facilitators, and specific room numbers. Building locations in the schedule below are tentative.
       
REGISTRATION INFORMATION
       
First Name:
       
Last Name:
       
Student ID number:
       
Year in School:
1st Year Sophomore Junior Senior
Other (Please specify)
       
Age (please specify):    
       
Major (please specify):    
       
Dual major
(please specify): 		   
       
Are you an RA? Yes No    
       
Choose first preference:
     
       
Choose second preference:
     
       
 Have you ever participated in an intergroup dialogue? Yes No
  If yes, specify:
       
Please explain your motivation to engage in intergroup dialogue about race and ethnicity.
 
       
What would you like to see come out of this experience?
 
Please describe your previous experiences with any multicultural events (e.g. workshops, symposiums, retreats etc.).
 
Please list any course(s) you have taken that included activities and information related to understanding race and ethnicity. How did the course(s) impact your views of racial/ethnic diversity?
 
       
How did you hear about the CARE program?
     
       
CONTACT  INFORMATION
       
During the academic year
  SU Email Address:
       
  Cell Phone:    
       
If you live on campus:    
  What Residence Hall do you live in?    
 
       
  What is your room number?    
     
       
If you are a non-residential student:    
  What is your address?    
    Local address 1:    
    Address 2:    
    City: State: Zip:    
       
DEMOGRAPHIC BACKGROUND AND IDENTITIES
To assist us in creating a diverse and well-balanced dialogue, we would appreciate your voluntary response to the following items. Your responses to this short form will be confidential.
       
Please choose the option for each category that best describes how you identify yourself, along with any additional details where there is space provided.
   
1. Racial/Ethnic Identification. Choose as many as apply, and please specify where appropriate.
 

African American or Black:

Asian American or Asian:

Latino/a or Hispanic:

Native American or American Indian:

European American or White:

Other (please specify):

       
2. Gender:
  Female    
  Male    
  Transgender    
       
3. Sexual Orientation:
  Bisexual    
  Gay    
  Heterosexual    
  Lesbian    
  Questioning    
       
4. Religious/Faith Identification:
     
       
5. Citizenship status:
  U.S. Citizen    
  Permanent U.S. Resident    
  Non U.S. Resident    
       
6. Disability, if any:    
       
7. Describe the racial/ethnic makeup of your high school student body:
  all or nearly all white    
  mostly white    
  approximately half white and half people of color    
  mostly people of color    
  all or nearly all people of color    
       
8. Please list any other group memberships or social identities that are important to you: