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Today's Date *

MM

DD

YYYY

Name *

First Name

Last Name

Gender Identity

Please select any/all choices with which you identify.

Cisgender man

Gender-nonconforming or Genderqueer

Non-binary

Transgender man

Two Spirit

Not mentioned above

Sexual Orientation

Bisexual

Gay

Heterosexual/Straight

Queer

Not mentioned above

Race/Ethnicity *

White/European American

White/European American/Multiracial

If you selected White/European/Multiracial please select all that apply?

African/African American/Black

Arab/Arab American/Middle Eastern

Asian/Asian American

Latinx

Native American/Native Alaskan

Not mentioned above

Class

Working Poor (Household income: $0 - $24,000; Net Wealth less than $4,800)

Working class (Household income: $24,000-$75,000 Net Wealth: $4,800-$170,000)

Middle class (Household income: $75,000 - $121,000 Net Wealth: $170,000)

Upper/ Managerial class (Household income: $121,000 - $431,000 Net Wealth: $500,000 - $10,000,000)

Owning class (Household income: Above $431,000 Net Wealth: Above $10,000,000)

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

At what level will you be joining this program? Please let us know if you require financial assistance. *

$18,000 - For those with wealth $5 million+ or from an organization with a budget or assets of $30 million+

$14,000 - For those with wealth $2 million+ or from an organization with a budget or assets of $20-30 million+

$11,000 - For those from organizations with budgets or assets between $10-20 million

$7,000 - For those from organizations with budgets or assets between $2-10 million

$3,000 - For those from organizations with budgets or assets of less than $2 million

For those who require financial assistance to attend.