CPD Pre-Service Teacher Application

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Please complete and submit the following information:

Last Name *

First Name (No Nickname) *

Home Street Address *

City, State, Zip *

Home Phone *

Cell Phone *

Email Address *

CSU, Chico Student ID *

Content Area *

Legally Assigned Gender *

Male

Female

Required

What is your gender identity

Pronoun you use to refer to yourself

She/Her

He/Him

They/Them

Other:

Clear selection

Ethnicity

Please select all that apply.

Hispanic or Latino

American Indian or Alaska Native

Asian

Southeast Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Other:

If you have any dietary concerns, please enter them here.

Are you a vegetarian? *

Yes

Would you like a general "G" CSU parking pass for the duration of the Institute? *

Yes

Would you like a Collaborative Professional t-shirt? *

Yes

If you would like a free t-shirt, please indicate your size and color choices.

Please choose one size bigger than normal as the t-shirts have been found to run a bit small.

Women's

Men's

Small

Medium

Large

X-Large

2X-Large

Black

White

Clear selection

How did you first learn about the CPD program? *

Please select all that apply.

Brochure

Posters

Bulletin Board

Friend or Relative

High School Career Faire

Honors Program Application

Upward Bound Presentation

Choose Chico Day

Other:

Required

If you heard about CPD on a brochure, poster, or bulletin board, please let us know where.

Why are you interested in participating in this institute? *

Submit

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