Summer Workshop for Teachers

Name:

Email address:

Mailing address:

School:

School District:

Degree:

Degree granting institution:

Are you a U.S. citizen, national, or permanent resident?
Yes No

Would you like to use accommodations on campus
Yes No

Courses commonly taught:

Relevant Professional Development (Please supply name of activity(ies), sponsoring agency(ies), and dates)

We will form small, subject-specific working group, which will prepare a first draft of an activity (with the associated mathematics) for piloting during the following year. You will be assigned to one group. Please indicate your assignment preference below by selecting your first, second and third choice.

You are required to make three choices.

First choice		Give a reason for your choice:

Second choice		Give a reason for your choice:

Third choice		Give a reason for your choice:

Two professional references:

Name:
Contact information:

Name:
Contact information: