Name: Email address: Home Address: City: State: Zip Code: Home Phone Number: School: School Address: City: State: Zip Code: School Phone Number: School Fax Number:
School Level: Elementary Middle School High School Kindergarten to Middle School Middle School to High School
School Setting: Urban Rural Suburban
Grade levels: (Check all that apply.)
K
1st
2nd
3rd
4th
5th
6th
7th
8th
Subjects Taught and Level
What science topics do you generally teach?
What currciulum materials do you use to teach science (e.g. Foss, Insights, STC, homemade units)?
Total Years of Teaching Experience (in all schools)
Major in college:
Minor in college:
Highest Degree Earned: Bachelors Masters Ph.D.
Depatment Head: E-mail: Phone: Principal: E-mail: Phone: Professional Reference: E-mail: Phone:
1) How did you hear about the Inquring Minds Institute?
2) What benefits do you hope to gain from participating in the institute?
3) Please describe any previous professional development you have participated in.
Are there any other teachers in your department/school who might be interested? Name 1: Email: Phone: Name 2: Email: Phone: Name 3: Email: Phone: