First name:     MI:     Last name:

 Email:
         (Please include an email address if you have one.)

 Home address:   

 City:    State:    Zip code: -

 Home phone: ( )  

Place of employment:
        (i.e. Program name, name of institution)

Department:

Work address:

City:    State:    Zip code: -

Work phone: ( )  

(You must enter a phone number here. The form will not submit without a number. If you prefer to use a home phone number here, you may enter that number rather than a work phone number.)

Prefer to be contacted at:    Home       Work

GREAT Center Region - select one: (If you are not sure which GREAT Region you need to enter, please look at our map of the GREAT Regions, locate your county and enter your region. Click here for the map.)

Primary teaching area: (Please select one.)

ABE      GED/ASE      ESL

Highest academic degree: (Please select one.)

Length of time in teaching adult education:

ABE:

GED/ASE:

ESL:

Preferred day(s) for focus group meeting** with other teachers and/or administrators:
     (You may choose more than one day.)

Monday   Tuesday   Wednesday   Thursday   Friday

**Focus group meeting may be held at your GREAT Center location.

Student focus group meeting:
(I am willing to volunteer students for a focus group meeting during one of my class periods.)

Yes      No      Other (i.e., not sure, will let you know later, etc.)

Thank you for participating in this important intiative. We will contact you in early October regarding your participation and date, time and location for the focus group meeting.