US Social Forum 2010: WESPAC Delegation Application (DUE MAY 23rd)
Your Contact Information |
||||||||||||||||
|
|
||||||||||||||||
|
Name |
|
|||||||||||||||
|
Address |
|
|||||||||||||||
|
Primary Phone |
|
|||||||||||||||
|
Secondary Phone |
|
|||||||||||||||
|
E-Mail Address |
|
|||||||||||||||
Cost (Let’s get this out of the way first) |
||||||||||||||||
|
Please see the amounts below. We worked very hard to fundraise to make it as affordable as possible. Please put down the maximum amount of money you would be ABLE to pay. In other words, how much you can pay, through fundraising and saving, so we can ensure that anyone can afford to attend.
Item: Estimated cost per person: What you are able to pay:
Totals: $ _220.00___ $ ________
|
|
|||||||||||||||
Personal Bio |
||||||||||||||||
|
Give a brief personal bio, including the work you do or are interested in doing. List any important information and any organizational/union/school/religious affiliation (if you attend a Mosque, Temple, Church, etc.) |
||||||||||||||||
|
|
||||||||||||||||
|
|
||||||||||||||||
Statement of Interest |
|
What do you want to see at the Forum? How do you intend to make the most out of the experience? Are you interested in being a part of a work brigade*, direct action**, volunteering, being on a panel, etc? How do plan to bring the experience of the Forum back to your life and activism? (*Work brigades are being organized for visitors to join with people from Detroit in projects such as community gardens or bike repairs. **Direct actions include protests and other forms of activism being planned by people in Detroit.) |
|
|
|
|
Other Questions & Information |
|
|
|
|
|
What is the earliest day you would be able to leave (June 20th or June 21st?) |
|
|
Will you be staying for the entire Forum? |
|
|
Do you have any special needs? |
|
|
Do you need childcare? |
|
|
Do you need a place to stay? Is a cot on a church floor enough or do you need a bed? |
|
|
Do you know people from the area who can house you? |
|
|
Do you want to pool money to buy food in bulk? |
|
|
Do you have any dietary restrictions? |
|
|
Do you want your name and email to be added to USSF national email list? (They send 1-2 emails a month) |
|
|
Do you have a driver’s license? What is your age? |
|
Additional Comments |
Anything else you want to add or that we should know? Other questions or concerns?
|
|
Person to Notify in Case of Emergency |
|
|
|
|
|
Name |
|
|
Relationship to you |
|
|
Address |
|
|
Primary Phone |
|
|
Secondary Phone |
|
|
E-Mail Address |
|
Deadline & Deposit |
|
This form must be emailed back to us no later than May 23rd!!! To secure a spot on the van, we will need a non-refundable contribution of $35.00 to ensure a seat in the van. We will discuss the registration process and other details with you. Concerns: |
|
|
More info contact Roger Drew, 914-316-8833 or Jalal Sabur, 914-439-1746 or return the forms by email to [email protected]. To reserve the seat in the van by May 23rd, all applications must be emailed by that date. We will contact you back shortly if there are too many reservations.
Please note this is NOT an application to go to the US Social Forum, which is open to everyone. This is strictly an application for a spot on the van being rented by WESPAC and to request any funding assistance you need. More info on WESPAC: www.wespac.org