REGISTRATION FOR THE ECONOMIC JUSTICE CONFERENCE
PROGRAM AND SERVICES SURVEY

Your registration for the conference includes the survey below. The results will be disseminated at the event. In order to provide relevant and useful information as well as to provide opportunities for collaborations, resource enhancement and referrals to conference participants, we request that you complete this brief and simple survey. The questions all pertain to services your organization provides to address the education achievement gap and fringe economy financial services. Thank you for your help.

I am unable to attend the conference, however, please include our organization’s information. (Don’t forget to fill out the survey.)

Organization Name:

Address:

Phone: Fax: Web Address:

Registrants (limited to 3 per organization)

1) Name Email Address:

2) Name Email Address:

3) Name Email Address:

Please check any of the educational services your organization provides. If you would be interested in technical assistance to provide and/or partner with others, please check the “tech asst.” box and provide a contact person.

Person filling out survey:

Org. provides this service Tech. asst. requested Service/Program Open enrollment (yes/no) Capacity Program days & hours Length of program (i.e., year round, # of weeks/months) Contact Person Fee Location
Tutoring
Homework Assistance
Sports
Arts
Summer Camp
Youth Literacy Classes
Early Childhood (Pre-k) Education
GED Classes
Partnership with local public schools
Private/Charter School
ESL Classes
Other:

Please check any of the financial services your organization provides:

Org. provides this service Tech. asst. requested Service/Program Open enrollment (yes/no) Capacity Program days & hours Length of program (i.e., year round, # of weeks/months) Contact Person Fee Location
Financial Literacy Classes
Individual/Household Financial Counseling
Credit Union Services
Individual Development Accounts
Other:

Additional Information:

PARTNERS