K-8
LEADERSHIP PROGRAM in DISCRETE MATHEMATICS

  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:

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:

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:

PREFERRED LODGING ARRANGEMENTS

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

_____ 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: