One-day Course Registration

Please complete and submit this application on or before November 6, 2025.

Name

First Name

Last Name

Phone

(###)

###

####

City

Zip Code

What pronouns do you use?

(She/he/they, etc.)

How did you hear about this program?

(please be specific with the connector: a friend, social media, another course, etc.)

What is your racial justice work? Where do you organize and with what groups of people?

(ie in an organization, community, synagogue, church, neighborhood, etc)

What embodiment practices do you do (for example, yoga, tai chi, aikido, time in nature, etc). Is there anything else you’d like to share with us about your healing path?

How do you think this course will support your racial justice work?

The questions in the next section bear no weight on your eligibility for this session, they help us balance needs and plan ahead for a well-supported session for each of us.

Are you local to or currently living in the area?

Yes

After reviewing the COVID-19 policy, is there anything you would need added to make this session accessible to you? Do you have any questions about the COVID-19 policy?

You can see the policy here: https://docs.google.com/document/d/1Bc4mthp3JxxZQJdZsG0qeS4TG5zXuMripvTu0fPWHx4/edit?usp=sharing

This course is offered on a sliding scale. Sustainer Rate - $250+: for those who have generational or inherited wealth. Supporter Rate - $200: for those comfortably paying their rent or mortgage and those being sponsored by an organization with sufficient budget. Grounded Rate - $150: for those who have a regular income and are paying their mortgage or rent. Equity Rate - $100: for those who are challenged to make ends meet. All of this only works if everyone pays at the level they are able - not at a level lower than what they can pay. Together we can create financial balance when we each pay in alignment with our abilities. Your registration fee pays a team of four to five facilitators a living wage, allows us to redistribute a minimum of 20% of funds to local Black and Indigenous groups as well as Black Organizing for Leadership and Dignity, and includes paying the ERJ Practice Manager for organizing and administrative fees associated with the course. The cost covers all of that and typically includes meals throughout the course well as snacks and drinks.

At what level will you be joining this course?

Pleas enter name and amount

Your payment will be due upon acceptance to the course. If accepted, do you plan to pay in one lump sum, or would you like to discuss payment plan options?

One lump-sum payment

I would like to discuss payment plan options

Donations and sponsorships of any amount to offset the cost of registrations for others are always welcome. Donations directly impact our ability to offer scholarships. We recognize that some people have access to funds that allow them to help pay for or offset the cost of other future participants. Especially if you are white, comfortably paying your bills, have an organization paying your tuition and/or have other class privileges, we hope you will consider the feasibility of making a contribution that is meaningful to you.

Yes, I would like to donate additional funds to offset the cost of registrations for others.

Yes, I would like to join a fundraising team to support the cost of the course.

If you are interested in contributing, please provide the amount below. Please note that contributing in these ways is not at all required to participate in this course.

$50 $100 $200 $500 $1000 Other

What access needs might you have around this session? What would make these four days possible and easeful for you? We invite you to name needs below.

(for example, I need to sit sometimes. I can’t be in the sun too long, etc)

What additional information would you like to know about our time together?

Is there anything you want us to know? Any questions for Dara or other organizers of this course?

One-day Course Registration

DARA SILVERMAN

CONNECT