Workshop Application Form

Contact InformationFirst Name:

Last Name:

Institution:

Department:

Address:

City:

Select a State:

Zip Code:

Phone:

Email Address:

Confirm Your Email Address:

(Please Note: Your email address is what we use to track your application and participation in the workshop. Be sure to use the same email address in all forms relating to your workshop participation. This email will also be our primary means of communication with you; please check that you have typed it correctly.)

Workshop InterestsIn what ways do you hope to benefit by attending this workshop?

What do you hope to learn or discuss at the workshop?

Where will you be teaching in the fall (if different from your current position)?

DemographicsGender:

Male
Female

Ethnicity (choose one):

Hispanic or Latino
Not Hispanic or Latino

Race (select one or more):
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Disability status (select one or more):
Hearing Impairment
Visual Impairment
Mobility/Orthopedic Impairment
Other
None

Citizenship (choose one):

U.S. Citizen
Permanent Resident
Other non-U.S. Citizen

Number of years of full-time teaching experience:

Number of years teaching at the college level:

Current position:

Is your current position a tenure-track position?

yes
no

Will you be in a tenure-track position next year?

yes
no
I've applied for one (or more), but haven't heard yet

Discipline:

or Other discipline:

Will you teach next fall at an institution that serves a large number of minority students?:

Yes
No

Which of the following best describes the department or program in which you will teach next fall:

Two year college (Associate is the highest degree)
Private four-year primarily undergraduate (BS or BA is the highest degree)
Public four-year primarily undergraduate (BS or BA is the highest degree)
Masters granting (MS is the highest degree)
Doctoral granting (PhD is the highest degree)