Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Organization Name
*
What is your title/role in the organization?
What are the racial/ethnic demographics of your students, clients, or constituents?
*
Please feel free to indicate if you are uncertain about the specific answer.
What are the racial/ethnic demographics of your organization?
*
Please delineate the racial/ethnic composition of each tier of the organization, e.g. "administrative staff", "teaching staff" (for schools); "board members", "service providers" (for non-profits). Please feel free to indicate if you are uncertain about the specific answer,
What supports do you seek?
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Please check all that apply. If none do, please write a brief description of what type of supports your organization seeks in the second-to-last answer-field below.
Are you considering our firm for more than one professional development experience or a series of engagements?
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What is the size of the audience you wish to serve with this/these professional development experience(s)?
*
Of the categories listed below, which best describe the learning opportunities that you/your organization would like explore?
Please check all that apply.
Please provide us with 2 -3 prospective dates and times that we may deliver your professional development experience(s):
*
What is the goal or objective that you wish to achieve with this/these support(s)?
If the point of contact for your organization is not the person named above, please provide their information below (first/last name, email and/or phone number):
Please use this space to provide us with any additional relevant information:
