Syracuse University

PLACEMENT REQUEST
for Intergroup Dialogue Courses


Fall 2008
       
Thank you for your interest in intergroup dialogue.

Please note that the deadline for placement requests  for  the Fall 2008 semester is Tuesday, April 1.  Beginning April 2, placement requests received by the deadline will be reviewed, and students will be notified about the status of their request by email or phone prior to registration.  We will continue to receive placement requests after the deadline, and if spaces are still available in the courses, make placements on an ongoing basis.  Decisions about placements into the courses will be guided by your interest in taking an intergroup dialogue course, in addition to a critical educational objective to achieve diversity and balance of a variety of social identities. This diversity and balance is crucial to the implementation of the unique Intergroup Dialogue curriculum.

You’ll need about 10 minutes to fill out this application.
 
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): 		   
       
Please indicate your interest in specific dialogue courses.
First
Choice		 Second
Choice

Third
Choice

 Fourth
Choice		 Not
Interested		  

Intergroup Dialogue on Race and Ethnicity

Intergroup Dialogue on Gender

Intergroup Dialogue on Sexual Orientation

Women’s Intergroup Dialogue
           
Please indicate which class meeting times you are available:

Available

 Not Available    

Tuesdays, 3:30-6:30  

Wednesdays, 3:45-6:45  
   
       
Have you ever participated in an intergroup dialogue course? Yes No
  If yes, specify for which dialogue course(s) and in which semester(s) did you participate?:
   
       
Have you ever applied to take an intergroup dialogue course before? Yes No
  If yes, specify for which dialogue course(s) and in which semester did you apply?
     
       
In the event we are not able to place you in an intergroup dialogue course this time, would you like to be a part of a listserv that receives emails about future course offerings and related activities in intergroup dialogue?
    Yes No
       
Briefly describe your interest in taking a course on intergroup dialogue - including a description of any previous course experience or other background information that you feel is important for instructors to know.
 
     
How did you hear about the course? (check all that apply)
  Information provided by my academic department
  Course postcard/flier
  Email invitation
  Facebook Ad
  From someone who took the course
  From someone in a student organization
  From a professor
  From a staff member
  From my resident advisor
  From my academic advisor
  From someone who spoke in my class
  Involvement Fair
  Table in the Schine Center
  Other
   
       
CONTACT  INFORMATION
       
During the academic year
Email Address:
       
Phone:    
       
Cell Phone:    
       
Local Address1    
Local Address 2    
City: State: Zip:
       
What is the best way to reach you?    
  email    
  phone    
  mail    
       
Alternate Contact Information
Please complete this section with alternate contact information, perhaps your parent's address, for example, to better enable us to be in touch with you.
 
Email Address:
       
Phone:    
       
Address1    
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.
   
1a. Your Racial/Ethnic Identification (Please mark all that apply):
 

African American or Black
 (specify national origin):

Asian American or Asian/Pacific Islander
 (specify national origin):

Latina(o)/Hispanic American
 (specify national origin):

Native American/American Indian/Alaskan Native
 (specify tribal affiliation):
Arab American or Arab
 (specify national origin):

White/European American
 (specify ethnicity/national origin):

Other (please specify)
       
1b. If you marked more than one racial/ethnic identity group in the previous question, which one do you identify with the most?
  I marked only one racial/ethnic identification in the previous question.
  African American or Black
  Asian American or Asian/Pacific Islander
  Latina(o)/Hispanic American
  Native American/American Indian/Alaskan Native
  Arab American or Arab
  White/European American
  Other (specify):  
       
1c. People have different ways of talking about race and ethnicity. In the U.S. we sometimes refer to people as “white people” or as “people of color.” How, if at all, do you personally identify with these terms?

I tend to identify as…

  A white person    
  A person of color    
  Both    
  Neither    
       
2. Gender:
  Female    
  Male    
  Transgender    
       
3. Sexual Orientation:
  Bisexual    
  Gay    
  Heterosexual    
  Lesbian    
  Questioning    
       
4. Do you feel that you grew up with (check only one):    
  More than enough resources    
  Not enough resources    
  Resources that were just right    
       
5. Please select the circle corresponding to the highest level of education completed by each of your parents or guardians
 
Years of School Completed Mother or female guardian Father or male guardian Other/additional parent or guardian
Not applicable or not sure
1-11 Years
High School Graduate
Some College
B.A., B.S. Degree
MSW, MBA, M.A. or other Master’s Degree

J.D., M.D., Ph.D., D.D.S. or other Doctoral Degree
       
6. Religious/Faith Identification:
     
       
7. Citizenship status:
  U.S. Citizen    
  Permanent U.S. Resident    
  Non U.S. Resident    
       
8. Disability, if any:    
       
9. Primary regional area where you grew up (please check all that apply):
  Urban    
  Suburban    
  Rural    
  Other    
       
 10. Please list any other group memberships or social identities that are important to you: