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* 1. District:

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* 2. Name and E-mail Address of District Contact:

List the following information for the district staff who will attend the collaboration meetings as part of the district cohort.

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* 3. Name of Cohort Member 1:

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* 4. District Role of Cohort Member 1:

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* 5. E-mail Address for Cohort Member 1:

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* 6. Name of Cohort Member 2:

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* 7. District Role of Cohort Member 2:

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* 8. E-mail Address for Cohort Member 2:

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* 9. Name of Cohort Member 3:

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* 10. District Role of Cohort Member 3:

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* 11. E-mail Address for Cohort Member 3:

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* 12. Name of Cohort Member 4 (OPTIONAL):

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* 13. District Role of Cohort Member 4:

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* 14. E-mail Address for Cohort Member 4:

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* 15. Name of Cohort Member 5 (OPTIONAL):

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* 16. District Role of Cohort Member 5:

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* 17. E-mail Address for Cohort Member 5:

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* 18. Please rank your cohort preference in order from most preferred (1) to least preferred (6).

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* 19. What curriculum is being used in your district for the following content areas? Please provide the curriculum name and publisher (if applicable). If more than one curriculum is being used, be sure to include all titles.

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* 20. If any district-wide interim assessments are being administered, list the assessment name and the vendor (if applicable).

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