“A Mile in My Shoes Walk” Registration Form
Last Registration Day - June 23rd, 2022
Event Information
Community Conversations Diversity Walk Share your story with someone of a different background to build a common understanding! Event Date: June 25th Event Time: 9:30 a.m - 11:30 a.m Event Address: Elm Ridge Park - 376 Elm Street, Rocky Hill, CT.
Attendee Information
Please complete required fields to be paired with walking partner.
Name
*
Prefix
First Name
Last Name
Racial and ethnic identity/group
*
E.g. Black, White, Asian, Hispanic
Religion
*
E.g. Christian, Muslim, Buddhist
Preferred Pronouns
*
E.g. she/her; he/him; they/them
Age Range
*
E.g. 18-24; 25-34; 35-44; 45-54; 55-64
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you need any special accommodations during the event?
E.g. parents w/children, wheel chair user
Would you like to be updated about the upcoming events?
Yes
No
Please verify that you are human
*
Submit
Should be Empty: