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* 1. What is your name?

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* 2. What is your role at Willow Elementary?

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* 3. What grade level(s) do you primarily work with or do your children attend?

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* 4. Can you commit to attending 4 Tuesday sessions on Jan 7th, Jan 14th, Jan 21st and Feb 4th from 5:30pm-7pm?

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* 5. What is your best email contact

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* 6. Please share cell phone in case we need to contact you last minute

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* 7. In regard to race and racism (i.e. power, oppression, white privilege) please rate your general level of knowledge.

New learner Expert
i We adjusted the number you entered based on the slider’s scale.

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* 8. Rate your comfort level engaging in conversations about race

Very Uncomfortable Extremely Comfortable
i We adjusted the number you entered based on the slider’s scale.

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* 9. As a participant in this book club what are you hoping to gain from this experience?

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* 10. Will You need child care for your school age children during book club? If so, please list their names and ages.

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