Grassroots Convening 2016: Registration Form

Registration closes on October 17, 2016

To be eligible to register, you must be a staff member, volunteer or board member of a California group that has received a grant from the Northern California Environmental Grassroots Fund, the California Wildlands Grassroots Fund or the Community Leadership Project. Fiscally sponsored projects of the Rose Foundation are also eligible.

Please note: You do not have to be a current grantee; all past grantees are warmly welcome.

Fields marked with * are required.

Personal Info

First Name *

Last Name *

Email Address *

Organization *

Cell or Daytime Phone *

Please enter as XXX-XXX-XXX

Street *

Street 2

Apt, Suite, etc.

City *

State *

Postal Code *

Meal Preference *

Meat

Vegetarian

Vegan

Gluten Free

Yes

No

Requiere usted servicios de traducción de ingles a español? (Do you require translation services from English to Spanish?)

Yes

No

If other, tell us how you will get to the convening

Stipends

If you qualify for a mileage stipend and/or hotel stipend, please complete this section.

Travel Stipend

If you would like to receive a travel stipend, what will be your one-way mileage to Berkeley?
(If you are not sure of the mileage, use maps.yahoo.com or mapquest.com.)

If you are traveling more than 50 miles one-way to attend the convening you are eligible for a mileage stipend as listed below (limited to two per group):

$50 If you are 51 – 100 miles (one way) from Berkeley
$75 If you are 101 – 150 miles (one way) from Berkeley
$100 If you are 151 – 200 miles (one way) from Berkeley
$150 If you are 201 – 300 miles (one way) from Berkeley
$200 If you are more than 300 miles (one way) from Berkeley

The travel scholarship checks will be disbursed at the conference when you check in.

Mileage to Berkeley

Hotel Stipend

If traveling over 200 miles one-way, you are eligible for a hotel stipend of $110. If traveling over 300 miles one-way, you are eligible for a hotel stipend of $220. (Limited to two per group. Please only apply if you need a hotel room. You are responsible for making your own hotel reservation and for paying for your room. We will give you a check when you arrive at the convening.)

Please make my check out to: (your name or your organization)

Photo and Sound Release

We use photographs and sound recordings from our conferences for educational, promotional and other purposes. By submitting this conference registration form, you are acknowledging that you have read and understood this photo release. (We promise to use your good side.) *

I agree

Each group can bring 2 people for free. Additional people cost $25 each (nonrefundable).

Each person attending the convening needs to submit a registration form. Each Group that has received a grant from Cal Wildlands or the Grassroots Fund can bring 2 people for free.

How many people will be attending from your group?

This registration form is for the 1st or 2nd person from our group (If so, no money is due)

This registration form is for the 3rd or more person from our group. (If so, please submit payment of $50 per additional person.)

Send checks to: Rose Foundation, 1970 Broadway, Suite 600, Oakland, CA 94612-2218

To pay by credit card, go to Rose Donation Center. Put name of the person for which you are registering in the name line.

Tell Us About Your Group

To provide you with the most helpful content and exercises during our gathering, please answer these five questions. These concern engagement - how you engage with your community in order to raise awareness, motivate action, attract volunteers and raise money - as well as how you tell stories about your work.

How would you describe the issues you are working on? (check all that apply) *

Environmental Education

Habitat/Wilderness/Preservation

Land Management/Urban Sprawl/Open Space

Sustainable Energy/Lifestyles/Climate Change/Transit

Agriculture/Gardens/Food Security

Sustainable Forestry

Toxics/Environmental Health and Justice

Water Resources/Watershed Protection

How does community organizing fit into your organization's strategy? (three answer limit) *

How would you describe your organizing ability skill level? *

Master Organizer

Experienced Organizer

Basic Organizer

Novice/Newbie

What is ONE burning question about building a grassroots environmental movement that you would like us to help you answer at our convening? (Please limit your question to 50 words)

Comments

Please tell us how to improve the registration process, or how we can make the convening better.

Please tell us how you heard about the Convening: *

Please CC this registration to:

Your confirmation is automatically sent to the registration email. You may use this field to send a copy to another email.