Placement Form
Education 202: Intergroup Dialogue - Exploring Social / Cultural Differences and Commonalities
Spring 2012 - 4 credits/General Education (SB) (U))
Social Justice Education Program
Name: ______Student ID#: ______
Phone: ______e-mail address______
School address: ______
Home address: ______
What is the best way to reach you? ______
Please note that this form is also available online at
or you can request a form by e-mail at
The following information will assist us in putting together a balanced, diverse group for each intergroup dialogue section. All information will be kept confidential.
1. Year in school (check one): ___1st year ___sophomore ___junior ___4th year senior ___5th year senior
2. Age (please specify): ______
Major or Program (please specify): ______If “undeclared,” what major are you considering? ______
3. Gender: ___Transgender _____ Woman _____Man _____Gender Queer
4. Race/Ethnicity (please check all that apply and specify where appropriate):
___African/African American/Black (specify national origin) ______
___Arab/Arab American/Middle East Descent (specify national origin)______
___Asian American/Asian/Pacific Islander (specify national origin)______Latina/o/Hispanic (specify national origin) ______
___Native American/American Indian/Alaskan Native (specify tribal affiliation) ______
___White/European American (specify ethnicity/national origin) ______
___Other Race/Ethnicity (specify) ______
5. Sexual Orientation: ___Bisexual ___Gay ___Heterosexual ___Lesbian ___Questioning
___Other (please specify)______
6. I am: ___ a U.S. student ___ an International student from ______
7. Religion/Faith Identification: Choose as many as apply. Please specify where appropriate.
___Agnostic ______
___Atheist______
___Buddhist ______
___Christian-Protestant (please specify)______
___Christian-Catholic ______
___Hindu ______
___Jewish (please specify) ______
___Muslim ______
___None______
___Other (please specify)______
8. Disabilities, if any:______
9. Primary regional area where you grew up:
___Urban ___Suburban ___Rural ___Various (please specify)______
10. Have you ever taken Educ395Z/Educ 201 before? ____yes ____no If yes, when? ______Which dialogue topic? ______
11. What do you hope to learn/gain from your participation in an intergroup dialogue?
12. What are some of your concerns about participating in an intergroup dialogue?
Course Sections
The following sections numbers of ED 202: Intergroup Dialogue - Exploring Social / Cultural Differences and Common Ground are scheduled for spring 2011:
Section # & Topic / Dates and Times#1:Race/Ethnicity & Gender Dialogue for All People
A dialogue for people of Asian, African, European, Latino/a, Arab, and Native American heritage of diverse genders and other social identities / Thursdays, 4:00-6:30 and Saturday, February 25, 9:00-5:00
#2:Race/Ethnicity Dialogue for White Peopleof diverse of diverse genders and other social identities / Thursdays, 4:00-6:30 and Saturday, February 25, 9:00-5:00
#3 & 4: Gender Dialogue for All Peopleof diverse genders and other social identities / Thursdays, 4:00-6:30 and Saturday, February 25, 9:00-5:00
#4:Race/Ethnicity & Gender Dialogue for People of Color
A dialogue for people of Asian, African, Latino/a, Arab, and Native American heritage of diverse genders and other social identities / Thursdays, 4:00-6:30 and Saturday, February 25, 9:00-5:00
13. Please indicate which section number and topic is your FIRST CHOICE and why:
14. Please indicate which section number and topic is your SECOND CHOICE and why:
All sections meet on Thursdays, 4:00 PM-6:30 PM, beginning Thursday February 2nd & Saturday, Feb. 25th , 9:00AM-5:00PM. Are you able to attend all of the scheduled sessions? ____ yes ____no
If no, please explain: ______
17. How did you hear about this class (check all that apply)?
___ flyer ___RA ___academic advisor ___friend ___instructor ___e-mail ___class presentation ___ student organization
___ information table ___ EDUC 202 web site ___ other
Please return this form to the department main office in 161 Hills South (between 9AM and 5PM) or in the program office in 364 Hills South. If the office is closed, place the form under the door. Placement will be considered on a first come, first served basis within the limits of reasonable group size and composition. The sooner you apply, the more likely we can place you in a section.
E-mail with any questions, or to request an e-mail placement form.
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