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*First Name Middle Name *Last Name *Email Click here to look up your profile by first name, last name and email Salutation Dr. Mr. Mrs. Ms. *Phone Fax School/Organization If Applicable Dept Title *Street 1 (McGraw-Hill cannot ship to a P.O. Box) Street 2 *City State -NA- Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas US Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Province Zip Code or Postal Code Country Afghanistan Albania Algeria American Samoa Andora Angola Argentina Armenia Aruba Ascension Island Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Botswana Brazil Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Europe Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Tobago Togo Tokelau Tonga Trinidad Tristan da Cunha Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, United States Western Sahara Yemen Zambia Zimbabwe *Please Indicate DLAM Program Choice (Elementary or Middle School) Course Questions *1.  Please select the appropriate program. Elementary School Program (2-5) Middle School Program (6-8) Both - Elementary and Middle School Camp Program Already have it - Thank you 2.  Where will you be using the Don't Laugh at Me curriculum? In one class In multiple classes School wide In other schools as well as my own 3.  I agree to fill out both the pre-implementation and post-implementation Teacher/School Counselor Questionnaire and administer the pre-implementation and post-implementation Student Questionnaire to my students. Yes No *4.  How many years have you been an educator, school counselor, school administrator, other? 1 2 3 4 5 6-10 11-15 16-20 21+ 5.  What grade level(s) do you teach? Please enter a combination of grades if needed - K, 1,2,3,4,5,6,7,8,other 6.  Is your school public or private? Public Private *7.  Are you a member of the PTA? Yes No 8.  Is your school a Charter school? Yes No 9.  Please tell us about your school setting. Select from the descriptions below. Rural Suburban Urban 10.  Would you be willing to participate in a survey that evaluates social and emotional learning and/or character education programs in your, and other, schools? Yes No Undecided 11.  Are you interested in professional development opportunities, for yourself, in social and emotional learning and/or character education? Yes No Undecided 12.  If yes, would you be interested in distance learning, in-person training, or both? Select one option below. Distance learning In-person training Both Undecided *13.  Would you like to join a Don't Laugh at Me (DLAM)email distribution list which will notify you of opportunities related to DLAM activities? Yes No Undecided *14.  If you are implementing the DLAM Camp Program, please indicate in which settings. Select from below: Summer camp After school program boys and/or girls club special education program (outside school) faith based group Corrections program Other Not implementing 15.  Do you expect that your Don’t Laugh at Me program implementation will be connected to or sponsored by a College of Education? Yes No Not sure 16.  Is your school currently implementing social and emotional learning and/or character education programs? If your response is YES, please answer the remaining questions. If not, please complete your registration by clicking on FINISH below. Yes No Not sure 17.  How many years has your school/organization been engaged in social and emotional learning and/or character education programs? 1 2 3 4 5 6 or more Not sure 18.  At which grade levels has such work been implemented? Grades 2-5 Grades 6-8 Grades 9 and/or higher Not sure 19.  If you know, please type in the names of the programs your school has implemented. 20.  How would you gauge the success of the above programs already implemented in your school? Very successful Moderately successful Successful Somewhat successful Unsuccessful

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