K-8
LEADERSHIP PROGRAM in DISCRETE MATHEMATICS

2000 Summer Institutes

Application Form

Alabama Commuter Institute
(July 17 - August 1)

(please print)


  NAME: ____________________________________________________________

  DATE: ______________________________

HOME ADDRESS


STREET: ____________________________________________________________

        ____________________________________________________________

  CITY: ________________________________________   STATE: __________

   ZIP: ______________________________

 PHONE: (    ) ______________________________

SCHOOL ADDRESS


STREET: ____________________________________________________________

        ____________________________________________________________

  CITY: ________________________________________   STATE: __________

   ZIP: ______________________________

 PHONE: (    ) ______________________________

E-MAIL ADDRESS

        ____________________________________

EDUCATIONAL BACKGROUND

 DEGREES |            INSTITUTION              MAJOR/DEGREE            DATE 
---------+-----------------------------------------------------------------
         |
 College |
---------+-----------------------------------------------------------------
         |
Graduate |
---------+-----------------------------------------------------------------

TEACHING and/or ADMINISTRATIVE RESPONSIBILITIES:

(Please describe below your present teaching or administrative responsibilities:)


A. What grade level(s) do you currently teach? ____________________

                                    supervise? ____________________

B. How many years of experience do you have as a teacher __________

                         or a supervisor of mathematics? __________

C. Please describe your present classroom situation
   (e.g. self-contained, open classroom, team teaching,
    subject area teacher, etc.):

   ____________________________________________________________

D. Do you have computers in your classroom? __________
   If yes, how many and what type of computers are in your classroom?

   ____________________________________________________________

SCHOOL INFORMATION:


What grade levels are taught in your school? ____________________

Is your school ... _____ Public?   _____ Rural?   _____ participating in an
                                                        SSI or USI program?
                   _____ Private?  _____ Urban?

                                   _____ Suburban?

FURTHER INFORMATION:

(On a separate sheet of paper, please list any of the following activities or experiences you have had in the past three years)

  1. Any additional courses or workshops you have attended.
  2. Any additional courses or workshops you have given.
  3. Any experience you have had with discrete mathematics, if any (including those more than 3 years ago).
  4. Any experience you have with the use of technology in the classroom, if any.
  5. Your activities in professional organizations.
  6. Your professional/administrative/supervisory activities within your school
    (e.g. curriculum development, math clubs, math specialist, etc.).
  7. Your community activities.

OTHER APPLICANTS FROM SCHOOL OR DISTRICT:

Are other teachers applying from your school or district? If so, provide names & grade levels.

SEX and ETHNIC ORIGIN

(optional) Please check one in each category:


_____ Male     _____ Native American    _____ Asian, or Pacific Islander

_____ Female   _____ African-American   _____ White, non-Hispanic

               _____ Hispanic           _____ Other: ______________________

WRITTEN RESPONSE:

Finally, to help us get a fuller picture of who you are, please (a) describe in a few paragraphs one of your most successful math activities and (b) tell us why you would like to participate in this program. Please give your answers careful consideration and limit yourself to two typed pages.

LETTERS OF REFERENCE:

Include (or have sent) two letters of recommendation: one from your school principal and one from your curriculum supervisor. Also include the Principal Authorization Letter signed by you and your principal.

Please submit this application as soon as possible, but NO LATER THAN May 1, 2000.
Applications will be accepted subsequently if space is available.
Send your application to this address:

Chris Rodger - LP Applications
Auburn University
Auburn, AL 36849-5307

You must print this application, fill it out, and mail it to the address above. Be sure to include all of the additional items mentioned in the application.

Application Info Page