| Application form |
| 1. Name |
Last, First, Middle Initial | |
| 2. School |
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| 3. Work Phone |
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4. Work Address |
Street, City, State Zip Code | |
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| 5. Home Phone |
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| 6.Home Address |
Street, City, State Zip Code | |
| 7.Email address |
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| Note - if mail is returned because an incorrect mailing address has been supplied, the application will no longer be considered. | | |
| 8. Number of years teaching |
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| 9. Number of years teaching physics/physical science |
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10. What you will teach next year?
(include grade level and level of course: AP, conceptual, etc.) | |
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| 11. To what extent are you available for follow-up meetings on weekends and during released days next school year? | | |
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| 12. Workshops you have taken in the last five years: | | |
| What | Where | Dates |
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| 13. Describe what (if anything) you have done that is innovative for a course, your school or other. | | |
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| 14. Formal Training: | | |
| Degree | Field | Year awarded |
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| 15. Number of formal courses in physics |
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| 16. What research experience have you had? | | |
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| 17. What research experience have you given your students? | | |
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| 18. Describe what you have done (if anything) with particle physics in your classroom? | | | |
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| 19. Additional comments: |
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