IA State Team Leadership Meeting

December 18, 2009
9:00 AM - 1:00 PM
Kirkwood Community College, Cedar Rapids, IA

REGISTRATION FORM

( * denotes required field )

Attendence: *

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

Last Name:

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First 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:

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:

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Phone:

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Fax:

E-mail:

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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.

What professional development programs do you have influence over (in the state), if any? If there are none, please input "None."
(Identify what professional development organizations or venues you have influence upon as we would like to identify organizations through which we may disseminate resources, training and data related to the STEM Equity Pipeline Project.)

*

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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