D and I Academy 
 
 
 
PERSONAL INFORMATION 
Salutation*
 
 
First Name*
 
 
Last Name*
 
 
Email*
 
 
 
Direct Telephone Number*
 
 
 
Job Title*
 
 
 
Company Name*
 
 
 
Industry
 
 
 
Department/Specialty
 
 
 

  
 
 
REQUIREMENTS 
 
 
  • Registrants must be tasked with implementing or influencing D&I initiatives at their organizations.
 
  •  Participants are required to take the Racial Equity Impact Analysis Training (REIAT), unless you have already taken it.
 
​​​​​​​​​​​​Have you taken the Racial Equity Impact Analysis Training? *  
Yes or No
 
Yes
No
 
 
 
 
 
 
QUESTIONS
Please provide detailed answers.  
 
 
 
 
Describe your role or interest regarding Diversity and Inclusion within your organization*
 
 

  
 
 
What would you like to get out of the Diversity & Inclusion Academy?*
 
 

  
 
 
If you know someone who might be interested in registering, please add their information below and we can reach out to them. 

  
 
 
First Name
 
 
Last Name
 
 
Email Address
 
 

  
First Name
 
 
Last Name
 
 
Email Address
 
 

  
First Name
 
 
Last Name
 
 
Email Address
 
 

  
Initial registration is limited to 3 people per organization. If you'd like to discuss registering more people, please reach out to Nancy McNamara here 

  
 
 
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