Extreme Energy Summit Registration

Thank you for taking the time to register for the Extreme Energy Summit taking place in Biloxi, MS January 30th - February 2nd, 2015. Please be aware that filling out this registration does not assure your acceptance as we have limited space and want to assure balanced representation. The deadline for submitting registration is December 13th. You will be notified of the status of your registration no later than December 15th.

Cost of the 3 1/2 day gathering is $250 with a sliding scale of $25-$250 (more if you can afford to support others with less resources). This will include meals, snacks, and overnight accommodations.

Please note, if you request a travel scholarship, the request deadline is December 21st. Please view travel ticket prices, mileage, etc. to estimate a cost of your scholarship needs.

First Name *

Last Name *

Title

Organization *

Address 1 *

Address 2

City *

State *

Postal Code *

Preferred Phone *

Fax

Email Address *

There are several housing options. Please indicate which of the following accommodations you would be comfortable with: (check all that apply) If you absolutely need a single room, please contact us. *

Dorm style housing

Room with 4 beds

Room with 2 beds

Nearby hotel (pay for and make your own arrangements)

A coalition of Gulf South groups is planning a site visit to communities impacted by energy infrastructure in Mobile, AL area before the start of the Summit. Are you interested/able to arrive on January 29th to participate? We ask those who are able to contribute some additional funds to cover food and lodging for an additional night. *

Yes

No

Unsure

Dietary Preferences/Restrictions

If you selected other for the question above, please specify here:

The cost of the 3 day summit is $250 on a sliding scale from $25-$250. Please indicate the amount you may be able to pay for your participation. *

If possible, would your group or organization be able to donate to other organizations or individuals with very limited funds? *

Yes

No

If you answered yes to the question above, how much can your group or organization donate?

If you will require a travel scholarship, how much money are you requesting? Please note that travel scholarship requests are only accepted through December 21. After December 21, travel scholarships will not be granted. *

We will be compiling a short biography from each Summit attendee to distribute at the Summit. Please include your name, organization/group affiliation/etc., the mission of your organization/group as well as a short summary of your work fighting extreme energy. *

This Summit will focus extensively on learning from each other's work and analyzing strategic successes. Much of our time will be spent in small groups focused on topics most critical to your work back home. These participant-generated sessions will be designed for sharing analysis of successes, workshopping new ideas, or learning more about an area you are struggling with or want to expand into. The sessions can cover a wide range of topics such as: how to stop oil trains, bringing anti-racism work to the white environmental movement, integrating with other social justice work, native and non-native collaborations, big green and grassroots collaboration, etc. What topics would be most relevant your work? Please indicate if you would be interested in helping lead a particular session.

To start sharing and discussing your ideas with other participants click here. *

We know that we do our best work when we can bring our whole selves. This Summit will include more time for cultural sharing. Please let us know if there's something specific you would like to share for your culture or cultural organizing.

This Summit will also focus on “networking the networks”, looking at existing networks and collaborations and identifying overlaps, gaps, and opportunities. What existing networks is your group a part of? *

Please rank the following activities in order of importance to you for this Summit. *

	Unstructured social time
	Structured networking
	Developing collaborative projects
	Movement messaging and strategy
	Topic-specific small groups
	Cultural sharing