Highlander Education Team Workshop Facilitation Request Form – Highlander Research and Education Center

Email *

Name *

First

Last

Phone Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Additional Email Address

Optional.

What are a few good dates/times to call you back to discuss your request?

Group or Organization *

Website or Social Media

Group Type

Geographic Region Served/Respresented

How many participants will be in the workshop?

What specific work is your group currently engaged in? What are your goals and/or what is your mission? *

What do you hope and expect your group will get out of the workshop? How will this workshop advance your work in your community? *

How is your group planning to apply what you learn in action? *

Describe the demographics of the group of folks who will participate in the workshop. *

Help us understand roughly the breakdown in terms of class, race, gender, sexuality, education, etc.

What else should we know about your group or the participants?

Date / Time *

Date

Time

Are these dates flexible? *

Location of Event *

Would you like to host the facilitators or would you prefer to hold the event at Highlander?

Amount of facilitation time requested

What topic areas is your group interested in? *