Registration Form

GENDER EQUALITY AND DISASTER RISK REDUCTION:
An Action Workshop for Social Change
REGISTRATION FORM

Please print out and submit the following information by fax or by mail with your registration fee to:

Penny Higa
East-West Center
1601 East West Road JAB 3017
Honolulu, HI  96822 USA
attn: Gender and Disaster Workshop

 

Name and Affiliation (as you wish it to appear on conference materials)

______________________________________________________
______________________________________________________ 

Contact information

E-mail: _______________________________

Telephone:____________________________

Fax: _________________________________

Mailing address: ____________________________

 _________________________________________

 _________________________________________

I am most interested in participating in Facilitated Workshop Number ______________.

Special accommodations:

The East-West Center is an accessible facility. Please advise us by August 2 of any special needs such as ASL interpretation: __________________

Dietary Restrictions/Meal preference:

            __Vegetarian

            __Other (please explain) ________________________

Workshop Expectations or Ideas

Please let us know any expectation that you have from this workshop or ideas that will contribute to the success of the workshop.  (These can also be submitted directly to: genderdisaster@yahoo.com.)

Registration fees 

Fees include continental breakfast and light lunch for three days and one working dinner, as well as all resource materials and a copy of the proceedings.

Regular: $125 if received by June 30 
Student/low-income: $105 if received by June 30
Late: $175 if received by August 9

Note: Refund requests cannot be considered after August 5, 2004.

Limited travel assistance is available for those from small-island Pacific states, Africa, Asia, and Latin America, with priority to participants with high travel costs and little organizational support. Submit your completed Travel Subsidy Application by MAY 1 for consideration.

Payment Details

Personal check or money order in US dollars should be made out to East-West Center (with a memo for Gender Disaster Workshop) and mailed to:

Penny Higa
East-West Center
1601 East West Road JAB 3017
Honolulu, HI  96822 USA
attn: Gender and Disaster Workshop

Credit card authorizations from Visa, MasterCard, American Express, Carte Blanche, Diners, and JCB should include account name, number, expiration date, signature and amount, and be faxed to the attention of Penny Higa at East-West Center:  808 944-7380.

__ I would like to charge my credit card for a total of USD  _____________________________

__ Visa __ Mastercard __ American Express __ Carte Blanche  __ Diners  __ JCB

Name on Card (please print):  ______________________________________________________

Card Number: ________________________________________________ Exp. Date: _________

Signature:  ______________________________________________________________________

US domestic agencies or organizations may also submit a purchase order (use East-West Center information above).

Acknowledgment of Receipt

All pre-registrations will be acknowledged and pre-workshop materials forwarded to you by e-mail or postal service.