3^rd Assembly of Caribbean People

Registration Form

Please be advised that the Registration Deadline is July 31^st!

(please indicate all selections by underlining)

Name:                                                                         Male/Female

Country of Residence:

Mailing Address:

Telephone:                                                  Fax:

Email:

Organization that You Represent (if any):

Position You Hold in Organization:

Social Sector:           Youth, Women, NGO, Trade Union, Peasant,         Environmental, Indigenous, Community (Community Based Organization), Religious, Cultural, Sporting, Small Business, Academic, Professional                        

You will Attend:      Youth Forum -      August 19^th            Yes/No    

                                       Women’s Forum - August 20^th            Yes/No

                   3rd Assembly of Caribbean People - August 20^th -23^rd     Yes/No

Proposed Arrival Date in Cap-Haitien:

Proposed Departure Date from Cap-Haitien:

Special Dietary or Medical Requirements:

Any other information:

Registration Fee- US$30.00

Please return completed form to acphaiti2003@yahoo.co.uk

Thank you for your cooperation. We look forward to seeing you in Haiti!