Inspire Madison Region/Rock County Online Career Coach Registration Form
Thank you for becoming an Online Career Coach for Inspire Madison Region & Inspire Rock County. By completing and submitting this form you give your permission for a background check to be conducted. Any adult using communication tools on Inspire Madison is required to pass a background check - the safety of students is always a top priority!

Once your background check has been completed, we will build your career coach profile in the system. When your profile is ready (allow 1-2 weeks) you will receive an email notification with log-in instructions so that you can view the profile. Remember, you can make changes to your profile anytime you'd like!

Don't hesitate to contact us at any time, with any questions or concerns. Our staff is here to help you make this a rewarding experience for both you and our partner schools/students!

Adrian Crabb
adrian@inspirewisconsin.org
608-345-8378
First Name *
Your answer
Middle Name *
Please provide your FULL middle name - not just the initial. This is needed for the background check. If you do not have a middle name, type "no middle name"
Your answer
Last Name *
Your answer
Company Name *
You can also type in options such as "retired" or "volunteer" or "independent consultant" if you are not currently working for a company
Your answer
Title/Position *
You only need to list your current title/position here
Your answer
Email address *
Your answer
Re-enter email address *
Your answer
Phone Number *
Your answer
Address
Your answer
City *
Your answer
How did you hear about us? *
Required
State *
Your answer
Zip Code
Your answer
Birthdate *
MM
/
DD
/
YYYY
Gender *
Your Careers - Career Title #1 *
You can tag your profile with multiple careers to show students the various fields you have experience in.
Your answer
Years in the Field *
Your answer
Roles & Responsibilities
400 Character Max
Your answer
Your Careers - Career Title #2
You can tag your profile with multiple careers to show students the various fields you have experience in.
Your answer
Years in the Field
Your answer
Roles & Responsibilities
400 Character Max
Your answer
Your Careers - Career Title #3
You can tag your profile with multiple careers to show students the various fields you have experience in.
Your answer
Years in the Field
Your answer
Roles & Responsibilities
400 Character Max
Your answer
Your Careers - Career Title #4
You can tag your profile with multiple careers to show students the various fields you have experience in.
Your answer
Years in the Field
Your answer
Roles & Responsibilities
400 Character Max
Your answer
Your Careers - Career Title #5
You can tag your profile with multiple careers to show students the various fields you have experience in.
Your answer
Years in the Field
Your answer
Roles & Responsibilities
400 Character Max
Your answer
Career Path History
400 Character Max
Your answer
Other Jobs You've Had
200 Character Max
Your answer
Association Memberships
200 Character Max
Your answer
Hobbies & Interests
200 Character Max
Your answer
I would like to offer/engage in Career Based Learning Experiences (CBLEs) *
If "yes" please answer the following question.
Select all of the student-facing Career-Based Learning Experiences you will offer/engage in *
You can select as many as you would like. You will also be able to go back and make changes as needed once your profile has been built. You can learn about Work-based Learning Activities here: http://inspiremadisonregion.org/careerbasedlearningexperiences/
Required
Select all of the educator-facing Career-Based Learning Experiences you will offer/engage in *
You can select as many as you would like. You will also be able to go back and make changes as needed once your profile has been built. You can learn about Career-Based Learning Experiences here: http://inspiremadisonregion.org/careerbasedlearningexperiences/
Required
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