DEI Collaborative Cohort 2 Intake Form
Pricing: Large Corporation/Foundation/Healthcare/Government: $3,000; Higher Education/Nonprofit/Small Business: $1,500
Participant Name
*
First Name
Last Name
Title
*
Company/Organization
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Pronouns
Ex: she/her, they/them, etc.
Dietary Restrictions or Preferences
Other Accommodations
Please let us know if there are any accommodations you need to be comfortable and engaged, such as closed captioning on Zoom, extra-wide chairs, etc.
Staff Contacts
Contacts for scheduling and invoicing
Assistant or Scheduler's Name
First Name
Last Name
Assistant or Scheduler's Email
example@example.com
Assistant or Scheduler's Phone Number
Please enter a valid phone number.
Your tuition amount
The amount that applies to your organization.
Invoicing Contact
*
First Name
Last Name
Invoicing Contact Email
*
example@example.com
Invoicing Contact Phone Number
*
Please enter a valid phone number.
Address for Invoicing
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
Should be Empty: