Registration Form

Please complete the following Safe Zone participant registration form. Registration forms must be completed at least 2 days prior to the training date. You will receive email confirmation once we have added you to the list of participants for a particular training. An email will also be sent to you the week before or during the training as a reminder and with training logistics (such as location). For any questions about the training, please contact Dennis Hisamoto at 949-824-3277 or lgbtrc@uci.edu.

First Name:

Last Name:

Name as you would like it to appear on your nametag:

Address:

City: State: Zipcode:

Zot Code:

Phone number:

E-mail:

Affiliation:

Faculty/Staff Deparment:

Undergraduate Student:
Major: Year:

Graduate Student:
Program/Area of Study:

Please list all Leadership Roles or Clubs/Organizations you have or currently participate in on campus (examples: T.A., Resident Advisor, Club Officier, Research Assistant, etc):

Training Date:

How did you first hear about Safe Zone training at UCI?

Thank you for your interest and participation in Safe Zone!

Questions? Call (949) 824-3277 or e-mail lgbtrc@uci.edu

	Comment	Hours: 9am to 5pm, Monday to Friday LGBT Resource Center G302 Student Center Tel: (949) 824-3277 Fax: (949) 824-7971
Produced by the UCI LGBT Resource Center, Part of the Student Affairs Family Copyright © 2007 UC Regents

Last Modified: 10/06/09