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Project Design Lab 2024
REGISTRATION FORM
June 24-28, 2024 / University of Vermont, Burlington
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YOUR CONTACT INFO
First Name
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Your answer
Last Name
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Your answer
Title
Educator content area and grade level, or staff/administrator position
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Your answer
Email
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Your answer
Cell Phone
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Your answer
Street Address 1
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Your answer
Street Address 2
Your answer
City
*
Your answer
State
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Your answer
Zip
*
Your answer
Emergency Contact Name
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Your answer
Emergency Contact Cell Phone
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Your answer
Emergency Contact Email
*
Your answer
COURSE SELECTION
Course Selection
*
The Art Room INsideOUT
Embracing AI in the Classroom
Building the Classroom Community
A Culture of Creative & Deeper Learning
The Bridges Project
Are you attending the PDL solo or as a team member?
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Team
Solo
I would like information about how to confirm a teaching artist residency to support implementing the project I design at the PDL.
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Yes
No
SCHOOL INFO
School Name
*
Your answer
School City/Town
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Your answer
Principal's Name
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Your answer
Principal's Email
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Your answer
Business Office Contact Name
The individual responsible for processing tuition payment
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Your answer
Business Office Contact Email
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Your answer
REGISTRATION TYPE / LODGING
Registration Type
Includes lodging (private air-conditioned dorm room), bed linens/blanket/pillow & bath towels, and breakfast and lunch. Everyone is on their own for dinner in Burlington
*
Three Graduate Credits - $2,000
Certificate of Participation for 40 hours of relicensing credits - $1,790
Reserve a room?
Lodging is included in your tuition fee: University of Vermont private air-conditioned dorm room with a centrally located private bath. Bed linens/blanket/pillow and bath towels provided.
There are optional evening events on June 25 and 26.
*
Yes
No
MEDIA RELEASE / DEMOGRAPHICS / QUESTIONS
MEDIA RELEASE
I give Community Engagement Lab the right and permission to use still photographs, video, and any digital media recordings of me, or reproductions thereof, for marketing, promotional or general communication purposes, including the use in any printed or digital media.
*
Yes
No
DEMOGRAPHIC QUESTIONS
Registering for a Community Engagement Lab event now includes some optional demographic questions for each registrant. We are asking these questions to better understand our audience and identify equity gaps in our programming. We take privacy and the confidentiality of Personally Identifiable Information seriously and will never release individual responses to anyone. The aggregate data collected in all our registration forms will be used to inform our approach to developing more equitable programs. The aggregate data will also be used in grant reports to organizations that fund our work.
How would you describe yourself?
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or of Spanish origin
Native Hawaiian or Other Pacific Islander
White
Other
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Gender?
Your answer
Pronouns?
Your answer
ACCOMMODATIONS
We invite you to let us know about specific accommodations you may need to participate in the Project Design Lab. We will make every effort to honor your request.
Your answer
QUESTIONS?
Let us know if you have any questions, or contact Paul Gambill, CEL Executive Director:
paul@communityengagementlab.org / 802-595-0087
Your answer
THANK YOU!
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