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Frostburg State University
Frederick Douglass Workshop
February 16 & 17, 2013
(Weather dates: March 2 & 3, 2012)

 

Frederick Douglass Workshop Application

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First Name*
Last Name*
Phone*
Mailing Address*
City*
State*
Zip*
Email Address
Affiliation(s)*
(institution, department, faculty/student/administrator, student organization, community organization, public position, private business, etc)
Occupation*
*Because of the limited roles in the game (30), and the desire to achieve maximum diversity (among institutions, university & school faculty, teachers & students, academics & public), "affiliation" and "occupation" may need to be employed to determine participation if applications exceed spaces.
I will attend*
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Food/meal preference*
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Food allergies or restrictions?*
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Describe*
Do you need disability access?
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Describe*
FSU is committed to making all of its programs, services and activities accessible to persons with disabilities. To request accommodation through the ADA Compliance Office, call 301-687-4102 or use a Voice Relay Operator at 1-800-735-2258. Frostburg State University is a smoke-free campus.
Gender*
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Hispanic/Latino(a)*
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Race*
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(select one or more)
Our funding agencies require that we report aggregate data on the demographic profile of those participating in this program. This information will not be published. Please answer all the questions above.