2012 FALL Dialogue for Change

Dialogue for Change Request to Participate

The Dialogue for Change will be held 10/4/12, 11/1/12, 2/7/13, and 4/4/13. Please visit our website www.niceconference.org for additional information.

A light meal will be provided each evening and trained facilitators will guide small dialogue groups. In order to ensure diverse representation, NICE will be inviting a representative group of seventy people to participate.

If you have questions regarding this request form, please contact Jamie Mundy at (815) 921-8476 or jmundy@kidsroe.org.

Before submitting your form, please review your answers for accuracy. The deadline for submission is 3 days prior to each session.


First Name *
Last Name *
Street Address (please use your address of residence) *
City *
State *
Zip Code *
Home Phone *
Email Address


In order to insure diverse representation, please answer the following questions:
Do you live within the boundaries of the Rockford Public School District #205 *
Do you work or own a business within the boundaries of Rockford Public School District #205? *
Do you have or have you had children enrolled in the Rockford Public Schools? *
Do you have or have you had children enrolled in a private or charter school? *
Do you have or have you had children who are home schooled? *
Are you a... *
Are you a... *
I would consider my race to be... *
I plan to participate in the Dialogue for Change on the following dates:
	*	10/4/12 Shared Learning 11/1/12 Intriguing Teaching 2/7/13 Innovative Classrooms 4/4/13 Engaged Communities