Historically American. Uniquely Caribbean. Globally Interactive.
Historically American. Uniquely Caribbean. Globally Interactive. Office of the President #2 John Brewer’s Bay ● St. Thomas, U. S. Virgin Islands 00802 ● Tel: (340) 693-1000 ● Fax: (340) 693-1005 RR1 Box 10000 ● St. Croix, U. S. Virgin Islands 00850 ● Tel: (340) 692-4024 ● Fax: (340) 692-4005 Email: manup@myuvi.net ● Website: http://www.uvi.edu MALE EMPOWERMENT CONFERENCE REGISTRATION FORM Name: Date: First Name Middle Initial Last Name mm/dd/yyyy Nickname: Date of Birth: Age: mm/dd/yyyy Physical Address: Gender: Street City, State Zip Code Mailing Address: Primary Phone Number: Street City, State Zip Code (###) ###-#### Email Address: Website Address: Secondary Phone Number: URL (###) ###-#### Occupation: School: Referred By: 1. What do you expect to gain from the Male Empowerment Conference? 2. What are your short-term and long-term career goals? IN CASE OF EMERGENCY Name of local friend or relative (not residing at same address): Relationship to participant: Phone Numbers (at least two): Participant’s/Guardian Signature: Date: mm/dd/yyyy
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Historically American. Uniquely Caribbean. Globally Interactive. Office of the President #2 John Brewer’s Bay ● St. Thomas, U. S. Virgin Islands 00802 ● Tel: (340) 693-1000 ● Fax: (340) 693-1005 RR1 Box 10000 ● St. Croix, U. S. Virgin Islands 00850 ● Tel: (340) 692-4024 ● Fax: (340) 692-4005 Email: manup@myuvi.net ● Website: http://www.uvi.edu MALE EMPOWERMENT CONFERENCE REGISTRATION FORM Name: Date: First Name Middle Initial Last Name mm/dd/yyyy Nickname: Date of Birth: Age: mm/dd/yyyy Physical Address: Gender: Street City, State Zip Code Mailing Address: Primary Phone Number: Street City, State Zip Code (###) ###-#### Email Address: Website Address: Secondary Phone Number: URL (###) ###-#### Occupation: School: Referred By: 1. What do you expect to gain from the Male Empowerment Conference? 2. What are your short-term and long-term career goals? IN CASE OF EMERGENCY Name of local friend or relative (not residing at same address): Relationship to participant: Phone Numbers (at least two): Participant’s/Guardian Signature: Date: mm/dd/yyyy