Touro College - Equity Assistance Center Region II

Equity Assistance Center Region II

EAC Home > Request for services form

REQUEST FOR SERVICES FORM

Contact Information
Name:
Position or Title:
District:
School:
Address:
City:
Zip:
Phone:
Email:
Additional Information
How did you hear about the EAC?
What is the problem you would like to address?
Is the problem district-wide or localized in a specific school(s)?
What kind of assistance are you looking for?
Reason for Inquiry
EQUITY FOCUS:	Race Gender National Origin
PRIORITY AREA:	Teacher Quality STEM ELLs Equity/School Climate/Diversity Bullying & Harrasment Drop Out Prevention Parent/CommunityEngagement

	Signature (Type your full name)

I CERTIFY that all statements and information furnished in this Request are true, complete and correct to the best of my knowledge and are made in good faith. I understand that statements or information furnished on this form are subject to verification and I agree to furnish supporting documents or information when so requested. I also understand that intentional misstatements or falsification may result in disciplinary action.


The Equity Assistance Center is a collaboration of the Lander Center for Educational Research and *For more information please contact Ms. Michelle O. Sheikh at* michelle.sheikh2@touro.edu *or (212) 463-0400 ext. 5109* Touro College is an equal opportunity institution.