Name(Required) First Last Organization(Required)Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you able to attend the entire day on June 18, 2025?(Required) Yes No Total miles from your address(Required)Total miles from your address listed above to the Colorado School of Mines – Ben Parker Student Center, 1200 16th St., Golden, CO 80401Please select the day(s) for which you are requesting lodging: Tuesday, June 17th Wednesday, June 18th Why are you interested in attending the the Roots of Change Conference?(Required)Please describe your involvement in sexual assault survivor advocacy and/or restorative justice work.(Required) Δ
