DIMACS Connect Institute 2001

APPLICATION FORM

The DIMACS Connect Institute is a six-week program (July 9 to August 3, 2001, including a 2 week follow up in Summer 2002: July 22 to August 2, 2002), held at Rutgers University in Piscataway, New Jersey. Participants must have e-mail access from May 2001 through August 2002.

Checklist:

1. Application form

2. Statement of Understanding - signed by applicant and school principal. page 1 and page 2

3. Two Letters of Recommendation. One from the school principal and one from the curriculum supervisor or department chair.

Although these items may be mailed separately, only complete application files will be reviewed. Deadline for submitting all documents: April 1, 2001 or until all available spots are filled.

Name:

E-mail (mandatory):

Social Security #:

School:

Address:

City: State: Zip:

Phone: Fax:

Home address:

City: State: Zip:

Phone:

Names of those writing letters of recommendation:

Principal:

Supervisor or Dept. Chair:

School type: Public__ Private__ Rural__ Suburban__ Urban__ Magnet/Special Topic__ Comprehensive__ Comments:

Is your school participating in any NSF Systemic Initiatives? SSI__ USI__ LSI__

Other:

Is your school participating in any NSF Curriculum Programs?

Where did you find out about the DCI Program? (Please be as specific as you can.)

Gender: Male__ Female__

Race or ethnic background:

Undergraduate degree: Year received:

Major:

Minor:

Graduate degree(s) or certification: Year received:

Graduate courses taken:

Have you participated in other NSF enrichment workshops or programs for teachers? Please give month/year(s) that you attended.

Please fill in all that apply (attach additional pages if necessary):

Classroom teacher (list grade levels and the number of years for each):

Math or computer science supervisor (list number of years):

Other (describe and list number of years):

List the courses that you have taught in school.

List the courses that you will be teaching in the next academic year.

Please describe briefly any leadership roles that you have had in your school or district in the last few years (curriculum development, Math or Computer Science Club(s), conference organization, district-wide presentations, etc.):

Describe how you've used computers in mathematics classes.

How frequently do you check your email?

Why do you want to attend this program?

What can you bring to this program to add to the experience for other participants?

Are you applying for a travel scholarship? yes ___ no ___

How much support are you applying for:

Please explain your need for such a scholarship:

If accepted into the program, what would be your preference for a roommate during the program:

Fellow Teacher ___ Research Program Participant ___