Request Assistance

First Name *

Last Name *

E-mail *

City / Town *

State *

Phone *

With what organization or agency (e.g., school district) are you affiliated? *

What is your role in your school/district/organization? *

Please briefly describe the reason you are contacting the Great Lakes Equity Center/Midwest and Plains Equity Assistance Center for assistance including any concerns about which you would like our staff to be aware. *

In a couple of words, please describe the topic of your request: *

How did you find out about the Great Lakes Equity Center/Midwest and Plains Equity Assistance Center? *

If you were referred by a colleague or friend, please enter their name and organization below: *

Is this your first time requesting service from an Equity Assistance Center? *

Provide three dates and times you and/or members of your team are available to discuss your request. Please indicate time zone.

First choice

Date *

Month

Day

Year

Time *

Hour

Minute

Timezone *

Second choice

Date *

Month

Day

Year

Time *

Hour

Minute

Timezone *

Third choice

Date *

Month

Day

Year

Time *

Hour

Minute

Timezone *

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