Request Assistance

First Name *

Last Name *

E-mail *

City / Town *

State *

Phone *

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

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.

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

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 *