ERASE RacismStudent Voices Campaign: TaskForce MeetingSaturday, January 6, 201812 PM – 2 PMReception Room, KellenbergHallMolloyCollege, 1000 Hempstead Ave, Rockville Centre, NY 11570

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To be completed by parent/guardian. As parent/guardian of:* This field is required.I give my permission for him/her to participate in the Student Voices Campaign: Student Task Force Meeting occurring on Saturday, January 6, 2018 from 12 p.m. to 2 p.m. at the Reception Room in Kellenberg Hall at Molloy College.
Name of Student
Name of School/Organization
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I agree that I will supply or approve transportation to and from the meeting. ERASE Racism will not provide transportation.* This field is required.
Yes
No
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I agree that ERASE Racism may use photographs, videotapes, audio recordings, or other transmissions of my child for public relations, educational or other purposes, including but not limited to use on the ERASE Racism Website, Facebook and Twitter pages or in newsletters and media releases. I agree that these materials shall become the property of ERASE Racism and release and discharge ERASE Racism and its representatives from any and all claims that may arise from the use of such property.* This field is required.
Yes
No
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Medical information including allergies:
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Dietary Needs (We will be serving lunch)
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Parent/Guardian Contact Information:* This field is required.
Name
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Home address
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Signature of Parent orGuardian * This field is required.
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