YWCA Dialogue to Change Interest Form

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Thank you for your interest! To sign up for an upcoming YWCA Day of Dialogue to Change Workshop, please fill out the form below.

These workshops are open to all community members and are facilitated by trained Dialogue to Change facilitators.

YWCA Dialogue to Change Workshops take place throughout the year and are part of our continued effort of working toward our mission of eliminating racism.

For questions, contact acollins@ywcanwo.org or 419.241.3235 ext. 122

Name *

Email *

Phone Number

Group Type *

Organization

Business

Individual

Other

Organization/Business

Estimated Number of Participants

Gender

Group (a separate form will be sent)

Female

Male

Non-binary/non-conforming

Prefer not to respond

Clear selection

Race/Ethnicity

Diverse Group

White

Black/African American

Hispanic/Latino

Asian American

Multiracial

Other

Clear selection

Age Range

Multi-Generational Group

18-25

26-35

36-45

46-55

56-65

Zip Code

Dialogue to Change has an action plan component. Would you be interested in participating in a short term project (3-6 months)?

Yes

If you selected yes for participating in a short term project, would you be willing to take a leadership role?

Yes

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