| Name: |
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| Address: |
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| Phone: |
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| Email: |
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| T-Shirt Size: |
Small
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Medium
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Large
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X-Large
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| Classification: |
Freshman
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Sophomore
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Junior
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Senior
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Faculty
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Staff
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| Major or Department: |
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What, if any, accommodations will you require to participate fully in the summit
(ASL interpreter, assistive/adaptive technology, etc.)? |
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| Racial/ethnic identity: |
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| Sexual Orientation: |
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| Socioeconomic Status (SES): |
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| Nationality: |
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| Ableness/Disability: |
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| Religion/Spirituality: |
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| Any other socio-cultural identity group membership you feel is relevant: |
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How would you describe the following settings?
1=Not Diverse to 5=Very Diverse |
| Your family (immediate & extended): |
1 |
2 |
3 |
4 |
5 |
| Your home community: |
1 |
2 |
3 |
4 |
5 |
| Your elementary school: |
1 |
2 |
3 |
4 |
5 |
| Your high school: |
1 |
2 |
3 |
4 |
5 |
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Current experiences in diverse settings:
How would you describe the following settings?
1=Not Diverse to 5=Very Diverse |
| Organizations of which you are a member: |
1 |
2 |
3 |
4 |
5 |
| Your living environment: |
1 |
2 |
3 |
4 |
5 |
| Your college classes: |
1 |
2 |
3 |
4 |
5 |
| Your friends: |
1 |
2 |
3 |
4 |
5 |
| Your social activities: |
1 |
2 |
3 |
4 |
5 |
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| Have you ever attended/taken a multicultural class, workshop, or training? Please list: |
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| Please list the student organizations or activities that you are currently involved in on/off campus. |
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| In a few sentences, please share why you are interested in participating in the Multicultural Summit. |
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For more information, please contact the Office of Diversity Services at diversity@suffolk.edu or (617) 573-8613
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