Diversity Circles, Fond du Lac, WI

Contact Us

I'd like to become a Fond du Lac Diversity Circle participant.
Use the form below or call 929-3622 to register.

Name:
Address:
City:
State:
Zip:
Gender:	Male Female

RACE/ETHNICITY
Please check which best describes your household Race/Ethnicity:*
	White Asian Asian & White Black/African American Black/African American & White American Indian/Alaskan Native American Indian/Alaskan Native & White American Indian/Alaskan Native & Black/African American Native Hawaiian/Other Pacific Islander Balance/Other
What is your household ethnicity:	Hispanic Non-Hispanic
Do you consider anyone in your household to be handicapped or disabled? Yes No
I do not wish to provide this information.

Daytime Phone:
Evening Phone:
Age:	Under 18 18-34 35-49 50-65 65+
Please register me for:	Circle #1 Circle #2 Circle #3 Circle #4
I am requesting translation for: Spanish Hmong
I will need transportation from/to the above street address. *To enrich the study circle experience it is of great importance that we have racial and ethnic background indicated.
Comments or Questions: