Museum of Tolerance

After this profile form is completed and returned we will begin to plan your Tools for Tolerance® program(s).

This profile will be confidential and only be used to help us design the program for your organization. This information helps orient our facilitation staff to your specific needs and concerns in order to make your program as meaningful and practical as possible. We encourage student participation in completing portions of this profile.

Contact Information

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Name:

First Name Required	Last Name Required

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Email: Required

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Street 1: Required

Street 2:

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City/State/ZIP:

City Required	State Required	ZIP Required

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Phone Number: Required

If you respond and have not already registered, you will receive periodic updates and communications from Simon Wiesenthal Center.

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Question - Required - Position/Title:

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Question - Required - School / Organization:

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Question - Required - Preferred Date 1:

Month

Day

Year

Question - Not Required - Preferred Date 2:

Month

Day

Year

Question - Not Required - Preferred Date 3:

Month

Day

Year

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Question - Required - Requested Arrival Time:

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Question - Required - Requested Conclusion Time:

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Question - Required - Total Number of students, grades 7 -12, including Adult Chaperones who plan to attend the MOT experience.:

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Question - Required - Mode of Transportation:

	Bus
	Van
	Private Auto
	Public Transportation
	Other

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Question - Required - DEMOGRAPHICS: Please provide student background info to help us better serve your group. (racial, ethnic background,gender,age,religion,etc.):

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Question - Required - Describe the community in which you teach (socio-economic, ethnic, size):

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Question - Required - BACKGROUND: Are the students familiar with each other? Please explain.:

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Question - Required - Please describe any on-going or previously conducted tolerance/diversity education programs and indicate the provider(s).:

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Question - Required - What existing policies/initiatives in your school/organization address issues of homophobia, racism, bullying, violence, etc.?:

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Question - Required - Please describe any incidents that have occurred or occur regularly related to any of the aforementioned issues.:

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Question - Required - What are your organization's long term plans in terms of accommodating and managing diversity?:

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Question - Required - PROGRAM GOALS: Are there any significant issues that the students may wish to address in a facilitated discussion?:

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Question - Required - What do teachers and staff expect the students to gain from their participation in the Tools for Tolerance program?:

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Question - Required - What do the students expect to gain from the program?:

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Question - Required - What follow-up initiatives are planned?:

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Question - Required - What do the students expect to gain from the program?:

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Question - Required - What follow-up initiatives are planned?:

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Question - Required - Assurance Statement:

I have read the FAQ, and understand the time and financial commitment required to participate in this program. Follow this link to the FAQ: www.museumoftolerance.com/TeensFAQ

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Question - Required - Select a program:

Standard Program (Six Hours)

Expanded Program (Eight Hours) Additional Speakers and Dramatic Performances

Expanded Program (Eight Hours) Youth Violence Prevention

Expanded Program (Eight Hours) Arts Based Activities

The fee for the program is $85.00 per person. Payment can be made by cash, check, Visa, Mastercard, and American Express.

Limited grant funds are available, please refer to the FAQ for details.

PLEASE NOTE: Once you press the submit button, you will be taken to an automatic confirmation page. Please do not close your browser prior to this confirmation appearing, as it will cancel your submission.

This is only a confirmation that your application has been submitted, not a confirmation of your program.

We will send you confirmation materials upon review of your application. If you do not hear from us please contact educators@museumoftolerance.com to confirm that your application was submitted.

We recommend printing or saving the contents of this form for your records, in case of submission processing error.

Inquire about additional specialized program options such as, skills-building workshops, sessions that explore a post 9/11 world, and pre-and post-video-conferencing opportunities. We will be happy to customize your program for you.

For additional information and to inquire about costs please call (310) 772-2548 or e-mail youthed@museumoftolerance.com.

Tools for Tolerance® for Teens Profile