CSA-Xenia STEAM Advisory Council Interest FormPlease complete this interest in its entirety. First Name * Last Name * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone (###) ### #### Mobile Phone (###) ### #### Email * Best way to contact you * Email Text Phone Call - Home Phone Call - Mobile Are you at least 18 years of age? * Yes No INTEREST IN COMMUNITY STE(A)M ACADEMY Please select the appropriate role(s) you would have on this advisory group: * (Select ALL that Apply) CSA-Xenia Parent/Guardian CSA-Xenia Grandparent CSA-Xenia Employee Non-profit Partner Business/company Partner Industrial Partner Local Government Arts/Humanities Partner Institute of Higher Education Partner Local Community Member with NO Other Affiliations Why are you interested in being part of the CSA-Xenia STEAM Advisory Group? If you have your choice on being part of a sub-group within this STEAM Advisory Group, which would you choose? (Please do NOT select more than 2.) Governance - Mission, Vision, Core Values, & Policies Operations - Facilities, Procedures, & Systems (e.g., communication) Academics - Curriculum, Instruction, & Assessment Workforce Skills - Credentials, Industrial Partnerships, Career Technology, & Work-based Learning Enterprises - Entrepreneurial Spirit, Business Partnerships, Real-world Experiences, & Service-learning STEM/STEAM - Project/problem-based Learning, Integration of Art/Humanities in Projects, & Makerspace/Design Thinking APPLICANT’S SIGNATURE: * DATE: * MM DD YYYY I understand submitting this interest form for the CSA-Xenia STEAM Advisory Group does not guarantee a position on the STEAM Advisory Group. * Yes No Thank you for your interest in building the culture of CSA-Xenia!
