California STEM Equity Pipeline State Team Meeting

Tuesday, May 5, 2009
10:00 am – 3:00 pm
Holiday Inn Capitol, 300 J Street, Sacramento, CA 95814
For hotel reservations call 916-446-0100

REGISTRATION FORM

( * denotes required field )

Attendence: *

Yes, I will attend. No, I cannot attend but would like to participate on the CA STEM Equity Pipeline State Team.

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Last Name:

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Title:

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Organization/Agency:

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Address:

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City:

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State:

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Please list any dietary restrictions (e.g., vegetarian, kosher, etc.):
Reasonable accommodations for individuals with disabilities will be made upon request. Please indicate if you have special needs.

Demographic Information

Please answer the following questions so that we may supply data on our participants required by our funder, the National Science Foundation. If you choose not to provide this information, please check the box at the bottom.

Are you...? *

Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.)
No, not Hispanic/Latino

The above question is about ethnicity, not race. No matter what you selected above, please continue to answer the following by marking one or more boxes to indicate what you consider your race to be.

What is your race? (Choose one or more) *

American Indian or Alaskan Native (A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.) Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.) Black or African American (A person having origins in any of the black racial groups of Africa.) Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.) White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.) I choose not to provide this information.

Gender: *

Female
Male
I choose not to provide this information.

Professional Position or Role/Responsibility: *

Teacher
Counselor
Administrator
Parent
Community Volunteer
Community Based Organization Staff
State Education Agency Staff
Other State Agency Staff
Business/Industry Representative
Other (specify)       

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