The Ohio State UniversityBell National Resource Center

National Black Male Retreat
A Black Male Imperative: Developing A Blueprint for Manhood

Friday, March 23, 2018 to Sunday, March 25, 2018
Deer Creek Lodge & Conference Center
Mt. Sterling, Ohio

Welcome to the Black Male Retreat registration site! We are excited that you have decided to join us for what will be a transformative time of personal development and relationship building. So that our time together is safe and productive, we need you to complete the registration form below.

REGISTRATION

Online registration will be accepted until Friday, March 9, 2018

Early Registration Fee* (on or before Friday, February 16, 2018): $250** per person
Registration Fee (February 18, 2018 - March 2, 2018): $300** per person
Late Registration Fee (after Friday, March 2, 2018): $350** per person

Forms of Payment Accepted: Cash, Checks, Credit Cards***, OSU eRequests, & Purchase Orders

NO REFUNDS WILL BE PROVIDED

* Early Registration Honored only by:
... Completing this Online Registration form on or before Friday, February 16, 2018
... and your Payment has been completed or postmarked no later than Friday, February 16, 2018

** Registration fee covers lodging, meals, and retreat takeaways.

*** Visa, MasterCard, American Express, & Discover

[*] = Required Fields Print
Registrant
 
 Personal Information
 Dr.Mr.Mrs.Ms. 
 * First Name
  
* Last Name
  
 Institution/Organization  (please do not use abbreviations)
 * Street address
  
 
 * City
  
* State
  
* ZIP Code
  
 *    (xxx-xxx-xxxx)   (xxx-xxx-xxxx)
 * Email Address
  
 Do you live on campus? Yes No
 
 Academic Information
 
 * Do you attend The Ohio State University? Yes No   
 Major:
 Minor:
 GPA:
 I am a student. 
 
 Emergency Contact
 * Name
  
Email address
  
Relationship to you
 Street address
City
State
ZIP
 
 * Telephone number:    (xxx-xxx-xxxx)
 
Retreat
 
 Housing
You will be housed eight (8) participants per room in loft-style lodgings or four (4) participants per room in bunk-style lodgings. If you have a roommate preference, you will have an opportunity to indicate such as soon as registration is closed. While indicating a roommate preference does not insure assignment to the same room, the registration team will make every reasonable attempt to consider your wishes.
 
 
 Transportation
You are responsible for transportation to and from the retreat.
 
 
 Accommodations
We encourage broad participation and will make reasonable accommodations according to the Americans with Disabilities Act (ADA) regulations. Please let us know of any accommodations needed.
 
 
 Meals
Five (5) meals will be provided for retreat registrants. Please indicate any food allergies or special dietary needs here.
 
 Other
Shirt Size:
 
 What would you like to gain from attending this retreat?
 
PaymentAmount Due: $300.00
 
  CashMust be physically delivered upon registration to the address listed below.
 
  CheckMust be U.S. mailed or physically delivered to the address listed at the bottom of this form.
Make checks payable to: The Ohio State University
A $30.00 fee will be assessed for all returned checks.
 
  Credit CardYou will be directed to the online payment system after you submit your registration.
 
  eRequesteRequest #:
OSU registrants can email the approved eRequest to either bennett.460@osu.edu or send it via FAX to 614-292-0051 or mail the original.
 
 
  Purchase OrderPO #:
Please email the approved PO to bennett.460@osu.edu or send it via FAX to 614-292-0051 or mail the original to the address below.
 
 
 

Completed Registration forms and fees may be sent to: Fax form to:

The Ohio State University 614-292-0051

Bell National Resource Center

ATTN: Robert A. Bennett III, Ph.D.

207 Hale Hall Direct Phone:

154 West 12th Avenue 614-688-3638

Columbus, Ohio  43210-1022
 
 
  I have read and agree to the Terms and Conditions.