Registration
Form
Where
Peace Lives International Mural Exchange Registration Form
Please
print out and fill in the information below, sign, date, and return to Where
Peace Lives at
mailing address below.
disclosed to any third parties.
Name
of Organization/School: _____________________________________________________
Address:
________________________________ City: ____________________State: ________
Zip
Code: _____________ Country: _______________________ Region: _________________
Mural
Program Coordinator/Liaison: _________________________________________________
Contact
Info: (Tel) _______________ (Fax) __________________
eMail:_________________
Start
Date for Program: __________________
End Date for Program: ______________________
Time
of program: _________________________
Approx. time per session: _________________
(i.e.
after school, during lunch, before school)
(i.e. one hour, 40 minutes, 1 1/2 hours)
Approximate
number of participating students: __________
Age range/Grade level: ____________
Mentor
Information (only if applicable) Please note that Where Peace Lives does
not assume any legal
responsibility and is not liable for any mentors interacting or working on
program at said school/organization.
Name:
__________________________ (tel) _________________ email:_____________________
Name:
__________________________ (tel) _________________ email:_____________________
Name: __________________________ (tel) _________________ email:_____________________
Name:
__________________________ (tel) _________________ email:_____________________
Name:
__________________________ (tel) _________________ email:_____________________
Name:
__________________________ (tel) _________________ email:_____________________
Your Information:
Sig:
______________________________________
Name:
____________________________________
Title:
______________________________________
Date:
______________________________________
Jeffrey
Clapp
Program Director
Where Peace Lives
Date:
10/17/08
Where Peace Lives Inc. — Conflict Resolution and Peacebuilding Through Art and Media
P.O. Box 2007, Red Bank, NJ 07701 U.S.A ¥ tel: 732.859.7637
www.WherePeaceLives.org
¥ info@WherePeaceLives.org