Personal Data |
|
|
First Name: |
|
Last Name: |
|
Preferred Phone*: |
|
Preferred Email*: |
|
* To contact you with questions and/or notifications. |
|
Home Street Address: |
|
Street Address (cont.): |
|
City: |
|
State: |
|
Zip Code: |
|
Home Phone: |
|
Cell Phone: |
|
Home Email: |
|
Please check your gender: |
|
Please check the group that best describes your ethnical/racial status: |
|
Please check your age group: |
|
|
|
Institutional Data |
|
|
School / Institution / Organization: |
|
School Type: |
High School
2-yr. College
4-yr. College
|
Street Address: |
|
Street Address (cont.): |
|
City: |
|
State: |
|
Zip Code: |
|
Work Phone 1: |
|
Work Phone 2: |
|
Work Fax: |
|
Work Email: |
|
|
|
|
|
Selection Criterion 1: Professional Qualifications and Teaching Experience
|
Academic degree(s) and major(s): |
|
Additional training: |
|
Total number of years teaching: |
|
Courses taught in school in the last 5 years: |
|
|
|
Selection Criterion 2: Implementation
|
Describe your interest in attending this workshop: |
|
Describe how you intend to use this training to augment instruction at your school: |
|
|
Additional Information (Does not affect selection) |
|
|
Will you bring a laptop with wireless capabilities to the workshop? |
Yes
No
|
|
Additional comments |
|
|
|