Historically American.  Uniquely Caribbean.  Globally Interactive. 
 
Office of the President 
#2 John Brewer’s Bay ● St. Thomas, U. S. Virgin Islands 00802 ● Tel:  (340) 693-1000 ● Fax:  (340) 693-1005 
RR1 Box 10000  ● St. Croix, U. S. Virgin Islands 00850 ● Tel:  (340) 692-4024 ● Fax:  (340) 692-4005 
Email: manup@myuvi.net ● Website:  http://www.uvi.edu 
 
MALE EMPOWERMENT CONFERENCE 
REGISTRATION FORM 
 
 
 
 
 
 
Name: 
 
 
 
Date: 
 
 
First Name 
Middle Initial 
Last Name 
 
mm/dd/yyyy 
 
 
 
 
 
 
Nickname: 
 
Date of Birth: 
 
Age: 
 
 
 
 
mm/dd/yyyy 
 
 
 
 
 
 
 
 
Physical Address: 
 
 
 
Gender: 
 
 
Street 
City, State 
Zip Code 
 
 
 
 
 
 
 
 
Mailing Address: 
 
 
 
Primary Phone 
Number: 
 
 
Street 
City, State 
Zip Code 
 
(###) ###-#### 
 
 
 
 
 
 
Email Address: 
 
Website Address: 
 
Secondary Phone 
Number: 
 
 
 
 
URL 
 
(###) ###-#### 
 
 
 
 
 
 
Occupation: 
 
School: 
 
Referred By: 
 
 
 
 
 
 
 
 
 
 
 
 
 
1.  What do you expect to gain from the Male Empowerment Conference? 
 
 
 
 
2.  What are your short-term and long-term career goals? 
 
 
 
 
 
IN CASE OF EMERGENCY 
 
 
 
Name of local friend or relative (not residing at same address): 
 
 
 
 
 
 
 
 
Relationship to participant: 
 
 
 
 
 
 
 
 
 
 
Phone Numbers (at least two): 
 
 
 
 
 
 
 
 
 
Participant’s/Guardian Signature: 
 
 
Date: 
 
 
 
 
mm/dd/yyyy