Nobis Project Medical Form

REGISTRATION FORM

Black Land Matters - October 14-16, 2022
Participant Name *

First Name Last Name
Participant E-mail *
example@example.com
Participant Cell Phone Number *

Area Code Phone Number
School / Organization Name *
Employment Title *
Grade(s) / Subject(s) Taught
I teach / work at a ... *

Public School Independent School Charter School Non-school Setting
I'm applying as an ...

Individual Group
The other persons I am applying with include:
STATEMENT OF INTEREST
Please explain why you would like to participate in this program. *
What do you hope to bring to your school/organization and students after participating in the program? *
What skills would you bring to the program? *
SCHOLARSHIP REQUEST

Nobis Project is committed to working hard to make participation in our programs as affordable as possible. There are a limited number of scholarships available for educators. Because aid is limited, please carefully consider all the resources available that might help fund your trip before deciding how much aid to request. Visit our website for suggestions of additional funding opportunities: www.nobisproject.org.

Scholarships are available first come, first serve so we encourage you to register early.
Requested Amount of Assistance

5% off total cost 10% off total cost 15% off total cost 20% off total cost
PAYMENT INSTRUCTIONS

Full payment is due at time of registration. Please mail $550 check to:

Nobis Project
PO Box 9304
Savannah, GA 31412

If you have requested a scholarship, you may wait to submit payment until after you have heard back regarding your award determination. If you prefer to pay by credit card, there is a 3% additional procressing fee. Contact us if you would like to pay by credit card, info@nobisproject.org.
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REGISTRATION FORM