Wisconsin Target/Pilot Site Registration

Tuesday, October 13, 2009

Location: The Wells Fargo Conference Room, which is NOT the same room where we met in April. It is still in the main building of the LTC-Cleveland Campus, Lakeshore Building. To see a map of the campus, go to http://www.gotoltc.com/campusmap/index.php. Once on this page, scroll down and select, “Cleveland campus map.” The Lakeshore building is “L”. Parking is best in the east lot behind L to the far north there are visitor slots and then the doorway is near that lot.

REGISTRATION FORM

( * denotes required field )

First Name:

*

Last Name:

*

Title:

*

Organization/Agency:

*

Address:

*

City:

*

State:

AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY *

Zip Code:

*

Phone:

*

Fax:

E-mail:

*

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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