"Together We Thrive"
Arizona PAX Summit
June 01-02, 2022
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1.
First Name
(Required.)
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2.
Last Name
(Required.)
*
3.
Email Address
(Required.)
4.
What gender do you identify as?
Female
Non-binary
Male
Prefer to self-describe, below
5.
Please specify your ethnicity.
Caucasian
African American
Hispanic or Latino
Asian or Asian American
Native American
Native Hawaiian or other Pacific Islander
Other/Unknown
Prefer not to answer
Organization Info
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6.
School/Organization Name
(Required.)
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7.
Position
(Required.)
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8.
What is the primary role of your school/organization?
(Required.)
Mental/Behavioral Health
Child Welfare
Education
Juvenile Justice
Foster Care
Early Childhood
Healthcare
Other (please specify)
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9.
What population(s) does your school/organization serve? (Check all that apply)
(Required.)
Children ages birth-5
Children ages 5-12
Teens ages 13-18
Adults
Families
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10.
What county does your school/organization serve?
(Required.)
Apache
Cochise
Coconino
Gila
Graham
La Paz
Maricopa
Mohave
Navajo
Pima
Pinal
Santa Cruz
Yavapai
Yuma
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11.
How did you hear about the PAX Summit?
(Required.)
Principal/Supervisor
PAX Trained Colleague
PAXIS Email
Social Media
Arizona Department of Education
Other (please specify)
