2021 Virtual Young Leaders Organizing Institute Registration

Welcome, to the first-ever Virtual Young Leaders Organizing Institute (OI) brought to you by Eye to Eye

Eye to Eye is a national non-profit on a mission to improve the educational experience and outcomes of students who learn differently. Whether this is your first time attending one of our events or you're a long-time supporter, we are so excited to welcome you to our first virtual OI.

You are at the forefront of our movement to change the world for people with learning differences (LD). The OI is going to be an empowering weekend of community building, leadership development, fueling the movement, and meeting some really cool people along the way.

That movement starts on Sunday, January 17th, 2021 11am-3pm PST / 2pm-6pm EST.

We can't wait to see you there!

Please fill out ALL the questions that follow to officially register. If you have any questions please reach Mentoring@eyetoeyenational.org

Your Information

First Name

Last Name

Cell Phone Number

Personal Email Address

Date of Birth

Gender

Please describe:

What race/ethnicity do you consider yourself?

American Indian or Alaska NativeAsian or Asian AmericanBlack, African, Caribbean, or African AmericanNative Hawaiian or Other Pacific IslanderWhite, Caucasian, Middle Eastern, or North AfricanHispanic or LatinoPrefer not to disclose

Please provide your mailing address

Mailing Address

City

State

Zip

Career

Are you currently employed?

YesNot at this time

How long have you been employed in your current position?

What field do you currently work in?

What is your desired field of employment?

Education

Are you currently enrolled in school?

YesNot at this time

When did you graduate?

What was your area of study?

Major and/or Minor Details

When do you anticipate graduating?

What is your area of study?

Major and/or Minor Details

Event Participation

Please rank your interests in breakout room topics

#1 Interest

#2 Interest

#3 Interest

#4 Interest

#5 Interest

#6 Interest

Would you be interested in being interviewed about any of the above topics and/or being featured as part of this event?

Yes!No, thanks

In your own words, what does an education system where all students with Learning Differences thrive look like to you?

In January we will have a new administration and a new Secretary of Education. If you were to meet with them, what would you recommend their top priorities be to make the education system work better for students with Learning Differences?

ADHD/ADD	Auditory Processing Disorder
Central Auditory Processing Disorder (CAPD)	Dyscalculia
Dysgraphia	Dyslexia
Dyspraxia	Executive Functioning Issues
Math LD	Non Verbal Learning Disability
Other	Processing Disorder
Reading LD	Reading Processing Disorder
Slow Processing	Visual Processing Disorder