Contact Information Form – CALM 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*
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 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
For in-person meetings, guest rooms can be provided for those who are traveling at least 100 miles roundtrip. Will you need a hotel room reserved for you?**
Guest rooms are for the night before the meeting, unless otherwise requested. Gail Rutan will send you confirmation information about your reservation at a later date.
- Yes
- No
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
- Administrator CEUs (ONLY for those with an Administrator license from the Board of School Administrators)
- No CEUs needed
SPECIAL NEEDS / DIETARY RESTRICTIONS
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)
- Dairy-free (for those with medical restrictions or allergies)
- Vegetarian
- Peanut and/or other nut allergy
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.