Print this form, complete it, and return it with your check to the address at the bottom. You may duplicate this form as needed. For office use only:
Applic. recd._______ Fee recd.________
Status: A______ W______ O______
Activity #_____________________

UNC-CH CENTER FOR MATHEMATICS AND SCIENCE EDUCATION

CB # 3500, 309 Peabody Hall, UNC-CH, Chapel Hill, NC 27599-3500
(919) 966-5922 or (800) 428-1045; fax (919) 962-0588; Email cmse@ email.unc.edu

Name of Activity: ________________________________________________________________________

Dates of Activity: ________________________________________________________________________


Name ____________________________________________________________ Date __________________

Home Address: ____________________________________________________________________________

Home Telephone #: (_____) _____ - ________ Soc. Sec. # _____ - ____ - __________

Email address _________________________________ Fax # (_____) _____ - ________

GENDER (circle one) M ...... F RACE/ETHNICITY
(circle one)		 Af. Am | Am. Ind. | Asian
Hispan. | White | ______
HIGHEST EDUCATION LEVEL (check one) CURRENT POSITION (check those that apply)
Some College ____________ Teacher ____________
Bachelors ____________ Supervisor ____________
Masters ____________ Principal ____________
6 year ____________ Preservice Teacher ____________
Doctorate ____________ Univ/Coll faculty/staff ____________
SDPI staff ____________
MAJOR OF LAST DEGREE ________________ Other (list)
__________________
____________
Not Currently Teaching ____________

TEACHING ASSIGNMENT CERTIFICATE AREAS (check all that apply)
Yrs in position ____________ (A)______ (G)______ (6 yr)____ (Doc)____
School System _________________ SUBJECTS GRADES ENDORSEMENTS
School _________________ Math________ B-K________ Math________
Sch. Address _________________ Science________ K-6________ Science________
_________________ _________________ Computers________ 6-9________ Computers________
Sch. Fax _________________ Elem.Ed.________ 9-12________ LD________
Scl. Phone _________________ Mid.Sch.________ K-12________ AG________
Grade Level(s) _________________ Other (list) Other (list) Other (list)
Area/subject(s) _________________ _________________ _________________ _________________
Schl. Setting (circle):

urban

suburban

rural

We have read the requirements for participation. if selected, the applicant agrees to attend the workshop, and we both will fulfill the commitments listed for this activity.

___________________________________________
Applicant (sign and date)		 ___________________________________________
Supervisor (sign and date)

(Please provide the following information. Use additional sheets if necessary.)

1) List any workshops or other professional development in science and/or mathematics that you have taken in the last three years and approximate dates:

 

 

2) List any professional associations of which you are a member.

 

3) List any leadership experiences you have had.

 

4) List the three things you think are most important when teaching.

 

 

5) List the goals you hope to attain through participation in this workshop.

 

 

6) Do you anticipate changes in the grade level and/or subjects you are currently teaching? If yes, please explain.

 

Return this application form and registration fee to:

Program Manager
UNC-CH Ctr. for Math. & Sci. Education
CB # 3500, 309 Peabody Hall
Chapel Hill, NC 27599-3500

Registration Fee Status (please check one):

____ Fee is enclosed.
____ Fee to be paid by school; please bill.
____ Fee to be paid by school system; please bill.

 

January 30, 2001

Center for Mathematics and Science Education
CB # 3500, UNC Chapel Hill
Chapel Hill, NC 27599-3500
(919) 966-5922

http://www.unc.edu/depts/cmse/applform.html

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