K-8
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(please print)
NAME: ____________________________________________________________ DATE: ______________________________ |
HOME ADDRESSSTREET: ____________________________________________________________ ____________________________________________________________ CITY: ________________________________________ STATE: __________ ZIP: ______________________________ PHONE: ( ) ______________________________ |
SCHOOL ADDRESSSTREET: ____________________________________________________________ ____________________________________________________________ CITY: ________________________________________ STATE: __________ ZIP: ______________________________ PHONE: ( ) ______________________________ |
E-MAIL ADDRESS____________________________________ |
EDUCATIONAL BACKGROUNDDEGREES | 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)
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OTHER APPLICANTS FROM SCHOOL OR DISTRICT:Are other teachers applying from your school or district? If so, provide names & grade levels.
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PREFERRED LODGING ARRANGEMENTS(for Rutgers residential applicants only):Arrangements have been made to lodge participants at a nearby Hotel each Monday through Thursday (double occupancy) at no cost to the participant; for single rooms and weekend nights, participants will be expected to pay approximately $38.00 per night. (Residents coming from a distance may NOT have to pay hotel costs for the weekend.) Please respond below:
_____ Yes, I am interested in lodging. _____ No, I am not interested in lodging. |
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.
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Please submit this application as soon as possible, but NO LATER THAN April
10. Applications will be accepted subsequently if space is available. Send your application to this address:
CMSCE |
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 |