You must have JavaScript enabled to use this form. 1 Start 2 Page 2 3 Page 3 4 Page 4 5 Preview 6 Complete District/Agency Information 1. District/Agency Name * 2. IRN Number (if known) 3. Phone Number * 4. Email * 5. District Demographic Data (select all that apply) * African American White Asian Pacific Islander Latinx Multiracial Free/reduced lunch Male Female Other Unknown African American African American (Total/%) * White White (Total /%) * Asian Asian (Total /%) * Pacific Islanders Pacific Islanders (Total /%) * Latinx Latinx (Total /%) * Multiracial Multiracial (Total /%) * Free/Reduced Lunch Free/Reduced Lunch (Total /%) * Male Male (Total/%) * Female Female (Total /%) * Other Other (Total /%) * 6. School Site Population Demographic Data * African American White Asian Pacific Islander Latinx Multiracial Free/Reduced Lunch Male Female Other Unknown African American African American (Total /%) * White White (Total /%) * Asian Asian (Total /%) * Pacific Islanders Pacific Islanders (Total /%) * Latinx Latinx (Total /%) * Multiracial Multiracial (Total /%) * Free/Reduced Lunch Free/Reduced Lunch (Total /%) * Male Male (Total/%) * Female Female (Total/%) * Other Other (Total/%) * District Contact for Grants Coordination 7. Contact Name: * 8. Phone Number * 9. Email: 10. Devices * Tablet Phone PC Laptop Printer Other... 10. Devices Other... 11. Programs/applications used/approved for On Site Use * Microsoft Office (Word, Excel, PowerPoint) Google Classroom YouTube Other Software... 11. Programs/applications used/approved for On Site Use Other Software... 12. Programming Format * In-Person Remote Hybrid Other... 12. Programming Format Other... 13. Choose the Day(s) of your Sessions * Sunday Monday Tuesday Wednesday Thursday Friday Saturday Sunday 14. Preferred Time(s) of Sessions * 2:30-3:00 PM 3:00-3:30 PM 3:30-4:00 PM 4:00-4:30 PM 4:30-5:00 PM 5:00-5:30 PM 5:30-6:00 PM 6:00-6:30 PM Other... 14. Preferred Time(s) of Sessions Other... Leave this field blank
