First Name: 

Last Name:

Preferred form of address:

  Mr.      Mrs.

  Ms.    Dr.

Home Addess:

Apt.: 

City: 

State:

Zip:  

Home Telephone: 

1  - -  - 

Social Security Number: 

  (i.e., 123-45-6789)

Ethnicity: (optional) 

Select the race with which you most closely identify.

African American

American Indian or Alaskan Native

Asian or Pacific Islander

White (not of Hispanic origin)

Multi-Ethnic:

Internet accessibility: 

         Home

  School

  Other: (list)

Preferred E-mail: 

Other E-mail: 

I check my e-mail:

         Daily

  Weekly

  Monthly

  Never

How did you learn about Program?

  Website

  Direct Mailing

  Other

  Administrator

 WW teacher

 Other (please specify):

Number of years teaching social studies:

Grades and subjects taught in the last six years: 

School Name:

School Address: 

School City:

School State: 

School Zip:

School Phone: 

1 - - -

School Fax: 

1 - - -

Principle ‘s First Name:

Last Name:

Superintendent’s First Name:

Last Name:

School District:

District Address: 

District City:

District State: 

District Zip: 

District Phone: 

1 - - -

Number of students enrolled:

  less than 100

  101 - 500

  501 - 1000

  1001 - 1500

  1501 - 2500

  more than 2500

Percentage of students who qualify for the federal free lunch program:

 %

The student body of my school is approximately: 

 % African American

 % American Indian or Alaskan

 % Asian or Pacific Islander

 % Hispanic

 % White (not of Hispanic origin)

 % Multi-Ethnic

Percentage Total: %

Undergraduate Institution:

               Degree:

Year:

Major:

Minor:

Graduate Institution: 

Year: 

Degree: 

Graduate Institution: 

Year:

Degree:

List any positions you have held in the social studies department: (i.e., chair, coordinator, resource teacher, mentor teacher)

Describe school or district activities you have been involved in that  directly relate to social studies education:
(i.e., curriculum developement, curriculum adoption, assessment development, professional development)

List any workshops or summer programs you have attended. Indicate where and when they were held and briefly describe the curriculum.
                                                                                       (7 lines)

Describe the extent to which you have considered the definition of terrorism and the passage of related legislation.

Describe your exploration of historical issues such as civil liberties in your classroom.

What do you need to learn about civil liberties?

How do you think attending this Woodrow Wilson
Commuter Institute will enhance your teaching?

Once You have reviewed your application you may press submit to send