REGISTRATION FORM WOMEN'S DAY - THURSDAY MAY 23, 2013
Registration/Check-in 12:00-1:00pm
Conference Begins 1:00pm
PLEASE COMPLETE THE FORM FIELDS BELOW (FIELDS MARKED WITH AN * ARE REQUIRED)
This event is FREE and OPEN to the public.
First Name: *
Last Name: *
Title:
Company/Institution:
Address: *
City: *
State: *
Zip: *
Work #:
Fax #:
Cell #:
E-mail Address: *
How did you learn about the conference? *
Facebook
Twitter
Conference Website
Word of Mouth
Newspaper

Internet Search
E-mail
Colleague
Poster
Direct Mail
Other
Other:

Please tell us more about you. As we identify corporate funders, often they want to know who our program reaches and how their funds will be used. Your response will help make the case for continuing the program with free admission for participants. This information also is helpful in determining future speakers and programming needs. Your personal information will not be shared, sold or distributed. The following sections are optional.

Race/Ethnicity (Check all that apply):
Native Hawaiian/Other Pacific Islander
Age:
Income:
Educational Attainment:
Employment Status:
Primary Industry:
Career Level:
Cancellation Policy: The Conference Planning Committee requests your help and commitment to ensuring that as many women as possible are able to attend this year's conference. If you are not able to attend the conference, PLEASE cancel your registration. If you registered on-line - please cancel your registration on-line using the confirmation number you received. If you registered via fax, mail or phone, please send an email to umkcwoclc@umkc.edu to cancel or call Heather Swanson at 816.235.2650.
ALL CONFERENCE DATES ARE FREE AND OPEN TO PUBLIC
REGISTRATION IS REQUIRED

THE WOMEN OF COLOR LEADERSHIP CONFERENCE | EMAIL: umkcwoclc@umkc.edu | PHONE: 816.235.1079 | FAX: 816.235.5588