Registration Form

Please Note: You must have completed basic Safe Zone training before participating in a Safe Zone Advanced course!

Please complete the following Safe Zone Advanced participant registration form. Note that you must complete the original Safe Zone program before participating in Safe Zone Advanced. 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 Sean-Patrick Doan 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: Select one Staff Faculty Undergraduate Student Graduate Student

Faculty/Staff Deparment:

Undergraduate Student: Major:  Year: Select one 1st 2nd 3rd 4th 5th

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: Select one Nov 17 - Beyond the Umbrella

Thank you for your interest and participation in Safe Zone Advanced!

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