“Revolution is not a one-time event.” - Audre Lorde Roots ConnectED Coaching Intake Form Name * First Name Last Name Email * Values and Beliefs: Where do you stand on your Values and Beliefs as an organization? * * Rate where you stand on the values and commitment on a 5-point Likert Scale question (Strongly Disagree to Strongly Agree) We believe in the long process rather than quick fixes to create systemic change. Strongly Disagree Disagree Neutral Agree Strongly Agree We see the role of personal transformation as critical to the work of collective (organizational practices and/or curriculum) transformation. Strongly Disagree Disagree Neutral Agree Strongly Agree We believe in reconstructing the ways in which the 4I’s of oppression manifest in school systems and culture. Strongly Disagree Disagree Neutral Agree Strongly Agree We value the inherent capacity of each human being and the value of each and every child. Strongly Disagree Disagree Neutral Agree Strongly Agree Commitments: What can you realistically commit to as an organization at this time? We are committed to… * Instructions: Rate where you stand on the values and commitment on a 5-point Likert Scale question (Strongly Disagree to Strongly Agree) … the long-term work and ongoing processes to support deep and authentic change. Strongly Disagree Disagree Neutral Agree Strongly Agree … giving resources (e.g. time, money, personnel) to see change in our institutions. Strongly Disagree Disagree Neutral Agree Strongly Agree … decentering the dominant perspective. Strongly Disagree Disagree Neutral Agree Strongly Agree … leading an institution in which centers anti-bias education can be implemented effectively. Strongly Disagree Disagree Neutral Agree Strongly Agree … consistently reflecting on our beliefs and practices. Strongly Disagree Disagree Neutral Agree Strongly Agree Organization Overview for Intake What is the mission for your school/organization? * Short answer What are the core values of your school/organization? * Short answer What do you value most about your school/organization? * Short answer How do you see the school/organization needing to grow? * Short answer How are decisions made when they impact the whole organization? * Check all that apply Collective input from all stakeholders Collective input from all staff Representative committees make decisions Top leadership makes decisions What is bringing you to this conversation on equity, justice, and anti-bias education? (Be specific if there was an event/observation that made you realize that you want to be strategic when thinking about anti-bias work at your school site.) * Short answer What collective training have you done around equity, justice, and anti-bias education? (Be specific about topic and last training) * Short answer How often do you provide opportunities for whole-staff training around equity, justice, anti-bias education? * Choose one Never provided one Weekly 1-2 times a month 1-2 times a quarter 1-2 times a year Sporadically Do you have a team at your organization/school site responsible for planning and executing professional development around topics of bias, power, privilege, and identity? * Yes No If yes, tell us a little about this group - who sits on it, how long has it been in practice, how often does it lead PD, etc. Short answer Additional Questions for Schools: How many students does your school serve? What grades does your school serve? If more than one site, please specify campuses and grades. What are the generals student population demographics? Racial: Gender: Grade level meetings: How often do staff members engage? * Select one Never Daily Weekly 1-2 Times a Month Quarterly Once a Semester Once a Year Sporadically Subject-Content Meetings: How often do staff members engage? * Select one Never Daily Weekly 1-2 Times a Month Quarterly Once a Semester Once a Year Sporadically Whole Staff Meetings: How often do staff members engage? Select one Never Daily Weekly 1-2 Times a Month Quarterly Once a Semester Once a Year Sporadically Self-Assessing Needs Instructions: Please read through the list below and complete the exercise underneath: *Click here to watch this video for more information on all topics below. Ranking: Please list in order (by #) the coaching needs listed above with the first choice you list being the most needed and the last choice being the least needed: Please give us more information on your ranking above: Short answer Please identify other needs you may have that are not included above: Thank you!
