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Texas Virtual PAX Summit
June 07 and 08, 2022
New to PAX
June 07th : 8:30am - 12pm, CST
Becoming a PAX-pert
June 08th: 12:30pm - 4:30pm, CST
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1.
First Name
(Required.)
*
2.
Last Name
(Required.)
*
3.
Email Address
(Required.)
4.
What gender do you identify as?
Female
Male
Prefer to self-describe:
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
*
6.
School/Organization Name
(Required.)
*
7.
Position
(Required.)
*
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)
*
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
*
10.
If you are a Teacher, what ESC do you serve? (Select from the dropdown)
If you serve the community, what county do you serve? (Please select County from the dropdown and type in the text box.)
(Required.)
ESC 1
ESC 2
ESC 3
ESC 4
ESC 5
ESC 6
ESC 7
ESC 8
ESC 9
ESC 10
ESC 11
ESC 12
ESC 13
ESC 14
ESC 15
ESC 16
ESC 17
ESC 18
County:
*
11.
How did you hear about the PAX Summit?
(Required.)
Principal/Supervisor
PAX Trained Colleague
PAXIS Email
Social Media
Other (please specify)
