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Contact Information Form – CCRS Cohort
For In-Person and Virtual Meetings
Date
MM slash DD slash YYYY
Name
*
First
Last
Email
*
Please make sure to enter your PREFERRED EMAIL, which will be used on a regular basis for ALL CORRESPONDENCE.
Enter Email
Confirm Email
ABE Program/Consortium/Site
*
Start typing to find program
OTHER - NOT LISTED HERE
MDE
AALC - LeSueur area
Adult Academic Program - Robbinsdale
Adult Options in Education - Hopkins
AEOA
Alexandria ABE
American Indian OIC/Takoda - Mpls
Bemidji ABE
Brainerd ABE
Burnsville School for Adults
Cambridge-Isanti ABE
Cass Lake-Bena ABE
Cedar Riverside Adult Education
CLUES
Dakota Prairie/Farmington ABE
Detroit Lakes ABE
DOC: MCF-Faribault
DOC: MCF-Lino Lakes
DOC: MCF-Moose Lake/Willow River/Togo
DOC: MCF-Oak Park Heights
DOC: MCF-Rush City
DOC: MCF-Shakopee
DOC: MCF-St. Cloud
DOC: MCF-Stillwater
Duluth ABE
English Learning Center - Mpls
Fairmont ABE
Faribault ABE - Faribault
Faribault County ABE - Blue Earth
Federal Bureau of Prisons
Fergus Falls ABE
Forest Lake ABE
Freshwater Education District
Glacial Lakes ABE
Guadalupe Alternative Programs
Harmony Adult Education Ctr/Metro East
Hastings ABE
Hennepin County Corrections
Hiawatha Valley/Red Wing ABE
Hmong American Partnership
Hmong Cultural Center
Hubbs Center/St Paul ABE
International Education Center/Lincoln - Mpls
International Institute - St Paul
Lakeville ABE
Literacy Minnesota
Lyndale Neighborhood Assoc
Mankato ABE
Metro NORTH ABE - Anoka-Ramsey CC
Metro NORTH ABE - Blaine/main office
Metro NORTH ABE - Brooklyn Center
Metro NORTH ABE - Columbia Heights
Metro NORTH ABE - Elk River
Metro SOUTH ABE
Minneapolis Adult Education
Moorhead ABE
Mounds View ABE
Neighborhood House
NE Regional Corrections Center
NW Indian Community Devel Ctr - Bemidji
NW Service Coop
Osseo ABE
Park Rapids ABE
Ramsey County Corrections
RAVE - Rosemount/Apple Valley/Eagan
Red Lake ABE
Rochester ABE
Roseville ABE
SE ABE - Albert Lea
SE ABE - Austin
SE ABE - Owatonna
SE ABE - Winona
South Suburban ABE
South Washington County ABE
SouthWest Metro Intermediate District
St Cloud ABE
St Croix River Education District
Stillwater ABE
Summit Academy OIC
SW ABE - Marshall
SW ABE - MN West/Jackson
SW ABE - Mountain Lake
SW ABE - MRVED/Granite Falls
SW ABE - Worthington
ThinkSelf - Deaf ABE
Tri-County Corrections
Vietnamese Social Services
WEST ABE
White Earth ABE
OTHER: If not listed above, what is your ABE program?
*
Address
*
Please enter the address where we can mail materials to you if needed.
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Phone
*
Please enter the phone number where you prefer to be reached.
Please note your gender pronouns. We collect this information for hotel arrangements and to be more respectful and gender inclusive in our work.
she/her
he/him
they/them
prefer not to answer
What is your role in the CCRS Cohort?
*
participant
facilitator
table coach
For the in-person CCRS Institute, ATLAS will reserve a room block for Wednesday and Thursday nights. ATLAS is able to arrange and pay the hotel directly for all guest rooms for those travelling over 50 miles to the venue. Please confirm:
*
PLEASE DO NOT CONTACT THE HOTEL DIRECTLY REGARDING GUEST ROOMS. All questions regarding guest rooms should go to Gail Rutan (
[email protected]
)
YES, I need a guest room in the ATLAS room block and ATLAS can pay my room and tax.
YES, I need a guest room in the ATLAS room block, but my ORGANIZATION needs to pay my room and tax.
NO, I do not need a guest room.
Which type of CEUs do you need? (check all that apply)
*
NOTE: Administrative CEUs are only for those who hold an Administrative license from PELSB.
Teacher CEUs
Administrative CEUs (ONLY for those with an Administrative license from PELSB)
No CEUs needed
ADDITIONAL NEEDS
Dietary restrictions/allergies that we can accommodate for in-person meetings:
If you have other dietary requirements, please feel free to bring your own food; we are limited in the types of diets we can accommodate.
Gluten-free (for those with medical restrictions or allergies only)
Dairy-free (for those with medical restrictions or allergies only)
Vegetarian - no fish
Pescatarian (those who don't eat meat but DO eat fish)
Peanut allergy
Other nut allergy
Multiple restrictions - will receive Garden Vegetable salad with vinaigrette
Other NON-dietary needs (to be accommodated to the best of our ability):
Do you require ASL interpretation?
Yes, I need ASL interpretation arranged for me.
Contact Us
Gail Rutan
Senior Events Manager
[email protected]
