Idaho EcosySTEM Directory Questionnaire

The Idaho EcosySTEM is in the process of updating our records, including contact information for all of our wonderful partners like you. Please complete the following form so we have your current information, and with your permission, this information may also be included in a password-protected, online directory to be available to EcosySTEM members for statewide networking and collaboration. (Please note that any person using the directory for any other reasons (e.g. marketing) will be removed from the directory and will be banned from its use.)

At the end of this form, you can indicate if you would like your contact information included in the EcosySTEM directory.

**You do NOT need to be on the directory to be considered a member of the Idaho EcosySTEM.**

Question Title

* 1. Contact Information

First Name *

Last Name *

Job Title *

Company/Organization *

Address *

City/Town *

State/Province *

ZIP/Postal Code

Email Address *

Phone Number *

Question Title

* 2. Please upload a current photo of yourself

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 3. Select which Educational Region you are in
Please refer to the Educational Regional Map to verify your region.

Region 1

Region 2

Region 3

Region 4

Region 5

Region 6

Statewide (select if your company/organization serves all of Idaho)

National (select if your company/organization serves all of the US)

International (select if your company/organization serves the US and other countries)

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* 4. Select the which statewide working group you are involved with, if any

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* 5. Which best describes your background and experience? Select all that apply.

Public School Educator

Public School Admin/Staff

Industry/Employment Representative

Nonprofit & Out-of-School Service Provider

Individual/Unaffiliated

State or Federal Agency Employee

Parent/Guardian

Student

Higher Education Professional

Librarian/Library

Tribal Employee

INNC Committee Member

ISEE STEM Committee Member

SWISH Committee Member

Other (please specify)

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* 6. What, if anything, would you or your organization be able and willing to contribute to your regional hub? (Not a requirement for participation.)

Examples:
~ Volunteering at events
~ Judging competitions
~ Providing specific resources and/or expertise on STEM
~ Donating to STEM opportunities
~ Providing meeting space for STEM opportunities
~ Being a guest speaker at different STEM events
~ Providing internship opportunities

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* 7. Would you like to be included in the Idaho EcosySTEM Directory?

Yes

As a tool hosted by Idaho STEM Action Center, the Idaho EcosySTEM directory may be subject to public records requests. Per Idaho Code §74-102(10)(f), which protects each citizen’s right to monitor the actions of state and local government entities by providing access to government records. STEM AC’s Public Records Request Policy.

Idaho EcosySTEM Directory Questionnaire

Question Title

* 1. Contact Information

Question Title

* 2. Please upload a current photo of yourself

Question Title

* 3. Select which Educational Region you are in Please refer to the Educational Regional Map to verify your region.

Question Title

* 4. Select the which statewide working group you are involved with, if any

Question Title

* 5. Which best describes your background and experience? Select all that apply.

Question Title

Question Title

* 7. Would you like to be included in the Idaho EcosySTEM Directory?

* 3. Select which Educational Region you are in
Please refer to the Educational Regional Map to verify your region.