North Carolina Physics and Physical Science
Modeling Workshops Summer 2008

Teacher Application

Select the workshop you wish to apply for:	Physics, June 16 - July 3, 2008
	Phyiscal Science, July 16 - July 3, 2008
	If I am not selected for this workshop I would like to attend the other workshop.
Personal Information
First Name
MI (required)
Last Name
Email (we must have a valid email to contact you about the workshop)
Home Phone
Home Address
Home City, State, Zip Code
Professional Information
Highest Degree
Institution
Year Received
School Name
School Phone
School Address
School City, State, Zip Code
County or School System
Certified	Yes in
	No
Job Title (select one that best applies to you and this workshop)	Teacher Classroom Support (not teacher) Building-level Administrator Central Office Personnel Choose One
Subjects/grades taught (select all that apply for the current or upcoming school year)	Elementary/PreK
	Middle school mathematics
	Middle school science
	High school mathematics
	High school biology/life science
	High school chemistry
	High school physical science
	High school physics/astronomy
	High school earth/enviro-science
	Support personnel (no students of your own)
	College
Number of students taught (select one)	Choose One 0-50 per semester 50-100 per semester More than 100 per semester
Commitments
Are you willing to attend a three-week summer workshop and three weekend (all day Friday and Saturday) follow-up sessions scheduled during the school year?	Yes
	No
Are you willing to give a conceptual test provided by the workshop staff this year (as a baseline) and next year as a pre-test and post-test?	Yes
	No
Are you willing to participate in classroom visits and evaluation using the Reformed Observation Teaching Protocol (RTOP)?	Yes
	No
Are you willing to participate in a Modeling teachers’ listserv?	Yes
	No
Is your principal and/or district science coordinator willing to observe the workshop for a day and discuss the program with participants?	Yes (make sure they register!)
	No
Interest
What summer professional development activites lasting 2 weeks or more have you participated in over the past 10 years?
Please explain briefly why you would like to participate in this workshop.
Comments or Questions?
Would you like to receive notification of other events at The Science House by joining our mailing list? You will receive one email per month and your email will not be shared with anyone else.	Yes
	No
	Already on the list
May we contact you after the workshop for additional information/feedback?	Yes
	No
The Science House at NC State University has the sole responsibility for selecting project participants based on the criteria set forth in the project description. I acknowledge that decisions of the selection committee are final. I certify that the information provided is complete and accurate to the best of my knowledge. If requested, I agree to provide proof of information I have given on this form. I acknowledge that I will participate in follow-up research and professional development opportunities during the course of the 2007-2008 school year. Falsification of information may result in termination of any financial support granted.

Not all applicants will be selected as project participants. Selection will not discriminate on the basis of race, color, religion, gender, national origin, or disability. If selected to participate in the Science House Modeling Program, the participant authorizes the release of program application materials as well the release of video tape, audio tape, photographs, questionnaire responses, or any other materials for use in program development, research publications, or project promotion.

For more information
Scott Ragan (919) 515 - 6118
Matt Greenwolfe
Patty Blanton

We hope to see you there!