The Loka Institute

Full Name:

Organization:

Street:

Street:

City:

State/Providence:

Zip: Country:

Day Phone:

Fax:

E-mail:

Race/Ethnicity:

(Your response is optional but we are committed to ensuring a diverse group of participants)

How did you hear about this conference?

Direct Mail    Email    Loka Website    Word of Mouth    Other

Are you Male    Female (this information is needed for matching roommates)?

While attending the conference would you be interested in being a Notetaker for one or more of the workshops? We are looking for people who can take clear and comprehensible notes that will later be used for writing the 2001 Conference Report.

  I would like to volunteer as a Notetaker (if you volunteer, we will contact you in advance to discuss details)

I am applying for (check one):

Partial Scholarship (Please choose)

   Travel Expenses* Room and Board (on-campus housing and meals) Registration Fee

Full Scholarship (travel expenses, on-campus housing, meals, and registration)

*Upon acceptance, we will notify recipients of the amount we have allotted for their travel. Scholarship recipients will be responsible for their own travel arrangements. Recipients will receive a reimbursement check for their travel after the conference when they submit their receipts. Special arrangements can be discussed if it is impossible for participants or their organizations to pay for travel up front.

Special Needs (Dietary, environmental, disability access & needs) please specify:

Please use the space below for a brief bio. This information will be used for the conference participation bio list unless you specify otherwise. (Please type or print clearly :-)

We ask that you answer the following questions (print clearly).

1)       Describe your current work and the community with which you work. Include a description of any community-based research projects you are involved with in your community.

2)       What will your participation in the conference bring to the community with which you work?

Please describe your plans for sharing what you learned.

3) Give an example of an experience in your life that has stimulated your interest in this work and your participation in this conference.

4) Explain your need for a scholarship.

5) Please include the names and phone numbers of two references that can speak to your work in the community.