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Program Starter Kit
East of California NetworkConsultancy In-Take Form
Profile of School
Student Organization (if applicable): _______________________________________
College/University: _____________________________________________________
Demographics of Students:
___%
Asian American
___% Latino
___% African American
___% Native American
___% Other (specify): _______________________
______ Total Undergraduate Population
Demographics of Faculty:
___%
Asian American
___% Latino
___% African American
___% Native American
___% Other (specify): _______________________
____ Total Faculty Population
Demographics of Staff/Administrators (list number/percentage, race/ethnicity,
and position):
___%
Asian American
___% Latino
___% African American
___% Native American
___% Other (specify): _______________________
____ Total Faculty Population
Which of the following exist at your school?:
Give a brief history of how the above were "established" at your
school (when, who initiated, etc.):
Profile of Student Efforts/Demands
What are the demands of student efforts?:
Comments:
How Many Students are Involved? _____
Give us a sense of who is involved in your effort (list
number/percentage of students who are 1st year, 2nd year, etc.;
race/ethnicity; student groups, etc.):
When did students begin mobilizing around this?
Describe what activities (i.e., forums, meetings with faculty/administrators,
documents) have been done, when, and what the results were:
List all faculty, staff, administrators who have been supportive:
On a separate sheet, describe what you need, what would you like
to get out of this consultance (Please be as specific as possible).
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