Which school or organization recommended you for this experience? *

Student First Name *

Student Last Name *

Email Address *

Phone *

Which of the following best describes you? *
Asian/Pacific Islander/ Pacific Islander/South Asian
Black/African American
Hispanic/Latino(a)/Latinx
Native American/Alaskan Native/American Indian
Middle Eastern
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Multiracial or Biracial, please specify
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Multiracial or Biracial, please specify *

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Gender Identity (Please select all that apply): *
Man
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Agender
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Prefer not to respond

Another identity, please specify

Do you identify as LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, questioning, intersex, and/or asexual)? *
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Midwest Learner Design Summit Part 1

July 19, 2023, 1 p.m. to 5 p.m.
Virtual

July 20, 2023, 1 p.m. to 5 p.m.
Virtual

Midwest Learner Design Summit Part 2

July 27, 2023, 9 a.m. to 6 p.m.

or

July 28, 2023, 9 a.m. to 6 p.m.

Cohorts select one date from above and attend together

I have read and understand the time commitment to participate in the Summit (Parts 1-2). Associated benefits are provided upon successful completion of the experience. *
- Select Option Yes No

Once you click the blue submit button below, you will see a submission page directing you to finalize your

2023 rep4 Midwest Learner Design Summit Part 1 Registration

Your registration is not complete until you finalize your Part 1 Registration