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Contact Information Form – Low-Literacy ESL Study Circle I

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
Hidden
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
- Administrative CEUs (ONLY for those with an Administrative license from PELSB)
- No CEUs needed
SPECIAL NEEDS / DIETARY RESTRICTIONS
Hidden
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
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]

Hamline University - ATLAS
1536 Hewitt Ave, MS-A1790
Saint Paul, MN 55104-1284

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This initiative is made possible with a grant from the Minnesota Department of Education using state funding from Minnesota Statute Section 124D.522.

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