North Carolina Physics, Chemistry and Physical Science
Modeling Institutes Summer 2010

Teacher Application

The 2010 Summer Modeling Institutes are currently full.
You are welcome to apply, however at this time your application will be placed on a waiting list. If/when a spot becomes available you will be notified by email or phone.
Thank you.

Order the institutes you wish to apply for: Order only the institutes for which you wish to apply. If you are not interested in a second or third choice please do not make a rank selection.	Choose One 1st 2nd 3rd Physics: Electricity, Light & Waves
	Choose One 1st 2nd 3rd Chemistry
	Choose One 1st 2nd 3rd Physical Science I: Physics,
Personal Information
First Name
MI (required)
Last Name
Email (we must have a valid email to contact you about the institute)
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 institute)	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 The following commitments are expected of all participants.
1. Are you willing to attend a three-week summer institute and three weekend (all day Friday and Saturday) follow-up sessions scheduled during the school year?
2. Are you willing to give pre- and post-conceptual tests to your students provided by the project staff?
3. Are you willing to allow project staff to visit your classroom during the school year to evaluate your use of modeling practices and administer the Reformed Observation Teaching Protocol (RTOP) evaluation tool?
4. Are you willing to participate in a Modeling teachers’ listserv?
Please check if you are willing to commit to the above stipulations:	Yes
	No
The following commitment is not a requirement for participation but is strongly encouraged. Strong administration support is considered an advantage in selection and participation.
5. Is your principal and/or district science coordinator interested in observing the institute for a day and discussing the program with participants?	Yes
	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 institute.
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
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 2010-2011 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 Project Director 919-515-5610
Angela Gard Project Coach
Patty Blanton Project Coach

We hope to see you there!