Please provide the following contact information:

First Name
Last Name
Middle Initial
Organization
Address Type	Home Work
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone (format xxx-xxx-xxxx)
Home Phone (format xxx-xxx-xxxx)
FAX (format xxx-xxx-xxxx)
E-mail
Confirm E-mail:
Mentor Group:	1 (2000-2001) 2 (2001-2002) 3 (2002-2003) 4 (2003-2004) 5 (2004-2005) N/A

SURVEY

Please take a few minutes to share some updated information with us and answer a few questions.

In what type of setting/role do you currently work? (check all that apply)

With what type of students do you currently work? (check all that apply)

    Gen ed

    EBD (please indicate levels:  I  II  III  IV  V) 

    LD

    Multi-Categorical

    Autism Spectrum

    Adult Learners

    Other:

    N/A

How many years of experience in the field do you currently have? Less than 5 5-9 10-14 15-19 20-24 25+

Please indicate your professional areas of interest/strength. (check all that apply)

Please indicate your interest in the following opportunities. (check all that interest you)

    Writing/editing chapters of a Mentor Book

    Serving on a committee to plan MIEBD mentor meetings (1-2 per year)

    Serving on a committee to develop a national mentor conference

    Serving as a representative for your Mentor Class (we are seeking one person from each of the 5 classes to serve as a representative to help facilitate communication)

    Organizing and maintaining the MIEBD Mentor Directory

    Joining the BICA Faculty to provide contracted training

    Other:

MIEBD Summer Institute Opportunities (July 28-Aug. 1 and Aug. 4-8, 2008 - Twin Cities)

1. Are you interested in attending an advanced mentor training course as part of the MIEBD Summer Institute? No Yes

2. Please share your ideas on topics that would be valuable for advanced training at the MIEBD Summer Institute:

3. Are you interested in visiting the Summer Institute to assist licensure students? No Yes

Other Summer Institute Comments/Ideas: 

International Child & Adolescent Conference XIV (Nov. 6-8, 2008 - Twin Cities)

1. Would you attend a MIEBD mentor meeting scheduled in conjunction with this conference? No Yes

International Conference Comments/Ideas: 

Regional Services

BICA is prepared to offer services throughout the region. Please indicate if you see a need for the following services in your area (check all that appy):

    Program Evaluation

    Program Design

    Program Improvement

    Local/Regional Training

    Other:

Please suggest topics that you see as currently important to your community/region for potential regional training: 

Please indicate the best timing for a regional training in your area (select all that apply)

Would you be willing to help facilitate a training session in your area if it worked into your schedule? No Yes

Regional Services Comments/Ideas: 

Please use this space to add any general comments

SPECIAL NEEDS: Please indicate if you have any special needs or requests.

THANK YOU!