July 29-31 2011Atlanta, GA

Name: _______________________________Date of Birth: _________________________Phone Number: ________________________Email Address: ________________________Home Address: ________________________City: _________________ State: _________Zip: __________________Do you have any special needs or restrictions(including dietary)? If so, please describe:_____________________________________

Be the Change is a drug and alcohol free event.

Hosting:

This year’s conve

rgence lodging willbe provided by attendees and staff membersliving in Atlanta. Please indicate whether yourfamily will be able to host or you will needlodging.

□

Can Host

How Many:____

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Need LodgingThere is a $50 registration fee which coversfood and expenses.

Please include cash or check made out to:

“Fair World Fair”

There are limited full and partialscholarships available to cover registrationfees and travel expenses. Please check belowif you would like to be considered for:

_____

Scholarship_____ Travel Expense AssistanceYou may also register online at

www.gapeace.org

or return this completed form to:

American Friends Service Committee60 Walton Street, NW, Suite 300Atlanta, GA, 30303

You may also fax this form to 404-586-0465.Once we receive your registration form, wewill follow up with you about further details.

Georgia Peace and Justice Coalition

The Be the Change Convergence will takeplace at the wonderful Horizons School inAtlanta. An ongoing partner and supporterof the activist community, Horizons islocated in the Candler park neighborhoodof north east Atlanta, conveniently withinshort walking distance of both theEdgewood/Candler Park and East LakeMARTA stations.For those unable to commute, lodging will

be provided by attendees’ families and

staff members living in Atlanta! We areasking that capable attendees providelodging for their fellow convergencemembers. All minors will be separated bygender and sleeping arrangements will behighly structured.Horizons is located at 1900 DeKalb Ave.N.E.Atlanta, GA 30307For more information please visit theirwebsite:www.horizonsschool.com

“Our only hope today lies in our ability to

recapture the revolutionary spirit and goout into a sometimes hostile worlddeclaring eternal hostility to poverty,

racism, and militarism.”

Dr. Martin Luther King, Jr., April 4, 1967