CA PLT Participant Info Form

✻ = Required

I. Professional Development Information

Date of Workshop ✻

Workshop location? ✻

Facilitator(s)? ✻

PD Event Type ✻

Up-to-half day (up to 4 hours) One full day or equivalent (5 - 8 hours) Two full days or equivalent (9 - 16 hours total) Up-to-five days (17 - 30 hours total) More than five days (more than 30 hours total) College or University Course

II. Participant Information

Your First Name? ✻

Last name? ✻

Gender ✻

Male Female Prefer Not To State

Ethnicity: ✻

Asian American Indian or Alaskan Native Black or African American Hispanic Native Hawaiian or Pacific Islander White Other Prefer Not To State

Preferred Mailing Address

City, State, Zip

School/Organization Representing:

Would you like to receive PLT updates and notification of new editions of the Branch, PLT's quarterly on-line newsletter? (Must enter Email Address next) ✻

Yes No

Email Address: Be certain that you have entered it correctly.

1. My position is (Check all that apply): ✻

If you check "Other" above, please describe

2. In what subjects do you plan to use Project Learning Tree? Check all that apply.
✻

If you checked "Other" above, please describe

3. How many students do you reach each year? ✻

<10 11-30 31-50 51-75 76-100 >100 N/A

Write In #

I plan to deliver PLT with 4-H Youth ✻

Yes No

4. What is the primary demographic of your students? ✻

Urban Suburban Rural N/A

What percentage of your students are:

American Indian or Alaskan Native ✻

Asian ✻

Black or African American ✻

Hispanic ✻

White ✻

5. How did you learn about Project Learning Tree? Check all that apply.
✻

Colleague School Administrator Professional Organization Conference/Exhibit Publications (PLT Newsletter, brochure, flyer, webiste) Media (magazine article, newspaper) Other, please describe

If you checked "Other" above, please describe

Additional comments?