Radical Refuge Long Island Pre-Registration

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When: May 10, 2024 - 8am to 4pm
Where: Choice for All - 55 Mansfield Ave, Roosevelt, NY 11575

Dress: Whatever you're most comfortable relaxing in

Thank you for your interest in the Radical Refuge Long Island retreat! This day has been designed exclusively with and for Latina and Black women early childhood educators in New York. Before completing this pre-registration form, please make sure you've explored our website radicalrefuge.org and are familiar with the event. If you have any questions, please do not hesitate to contact us through the website radicalrefuge.org.

Email *

Email Address *

Full name *

Pronouns *

she/her

he/him

they/them

Required

Optional: Social media handles (e.g. Twitter, Instagram, LinkedIn, Facebook)

Would you like us to share your contact information with other educators attending the convening?
*

Yes, please share my name, email address, and social media (if applicable)

No, please do not share my name, email address, and social media (if applicable)

Yes, please share my information, but only share my __________ (Add preference at very end of form)

Other:

How do you identify?
*

I identify as Latina

I identify as Black

I identify as Afro-Latina

None of the above

Other:

How do you identify? *

I identify as a woman

I do not identify as a woman

I identify as female since birth

I do not identify as female since birth

What is your role in early childhood education (ECE)? *

I am a classroom teacher who currently works directly with ECE children in the classroom

I am an assistant teacher who currently works directly with ECE children in the classroom

I am a paraprofessional who currently works directly with ECE children in the classroom

I am a home-based or family-childcare ECE provider who works directly with ECE children

I am a family engagement specialist who works directly with ECE children

Other:

Where is your ECE educator job located? *

Nassau

Suffolk

Do you have any dietary preferences? *

• None

• Vegetarian

• Vegan

• Dairy free

• Gluten free

Other:

Do you have any dietary allergies? Or others that we should be aware of for the retreat? *

We will be engaging in various activities, several of which will take place while sitting on the ground (e.g., breathing exercises, rest). Please let us know how this feels to you. We will provide yoga mats but you are welcome to bring your own comfort supplies (e.g., yoga mat, pillow, ear plugs) *

Sounds cool! I'm fine with sitting on the floor. *

I'm a bit concerned about this. (Please share more below)

Other:

Please share any additional accommodations that you may need (e.g., breast feeding room, wheelchair access)

Would you need childcare services in order to attend?
*

Yes. I can ONLY come to this convening if childcare services are provided.

Maybe. Childcare services would be great, but I can find alternative care if I have to.

No. Childcare is not an issue for me.

If you selected "yes" or "maybe", please share the number of children who would need childcare and their ages below.

Thank you!

We are thrilled that you would like to register for the Radical Refuge - Long Island. Someone from our team will reach out to you shortly to share next steps for attending this wonderful event.

A copy of your responses will be emailed to the address you provided.

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