1.First Name

2.Last Name

3.Email

4.Education Institution Type

School District

Charter School

Private School

Community Center/Non Profits

Higher Education/foundation/Government agency etc.

Other (please specify)

5.School City, State and Zipcode

6.What grade do you currently teach?

Elementary

Middle School

High School

Graduate School

Other (please specify)

7.What course do you currently teach?

8.Which category best describes you?

White (Eg: German, Irish, English, Italian, Polish, French, etc)

Hispanic, Latino or Spanish origin (Eg: Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc)

Black or African American (Eg: African American, Jamaican, Haitian, Nigerian, Ethiopian, Somalian, etc)

Asian (Eg: Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, etc)

American Indian or Alaska Native(Eg: Navajo nation, Blackfeet tribe, Mayan, Aztec, Native Village or Barrow Inupiat Traditional Government, Nome Eskimo Community, etc)

Middle Eastern or North African (Eg: Lebanese, Iranian, Egyptian, Syrian, Moroccan, Algerian, etc)

Native Hawaiian or Other Pacific Islander (Eg: Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, etc)

Some other race, ethnicity or origin

Other (please specify)

9.Gender

Women

Man

Gender Fluid

Genderqueer

Agender

Non Binary

Unsure

Prefer Not to say

Other (please specify)

10.I confirm that I will attend both sessions on April 25 and May 2nd from 4 to 5:30 pm.

Yes

No