ABOUT YOU

Name: Race/Ethnicity: (Optional) American Indian or Alaskan Native Asian Black or African American Hispanic or Latino White or Caucasian Pacific Islander/Hawiian Native Other please specify: Age Highest Educational Level: High School College Degree Graduate Degree Other please specify: Area of expertise How did you learn about the ACT National Workshop? EMPLOYMENT Employer City State Zip Code: Phone: Fax: Email Address Position Title

Please describe your current responsibilities, including information about ages and the types of services or
education you provide to individuals or groups, as well as programs/activities you are involved with.

EXPERIENCE

Please describe your professional or volunteer experience with program implementation

Please indicate three major issues and challenges you have faced when implementing programs
in your workplace and/or community

Not applicable; I don't have experience
Have commitment from my organization
Time required for involvement
Lack of knowledge of how to implement a program
Lack of funding
Political and "turf" issues
Lack of motivation and interest in my community

Other:


Please describe your professional or volunteer experience with conducting training and public speaking

List three things you want to learn at the ACT workshop