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 the Leadership Program for Teachers?

  Website

  Direct Mailing

  TORCH workshop

  Administrator

 WW teacher

  Conference

If Conference (please specify): 

Other (please specify): 

Present teaching position:

Grades:

Subjects: 

Number of years in science teaching

School Name:

School Address: 

School City:

School State: 

School Zip:

School Phone: 

1 - - -

School Fax: 

1 - - -

Principle ‘s First Name:

Last Name:

Super’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 science department: (i.e., chair, coordinator, resource teacher, mentor teacher)

Describe any of your school or district activities directly related to science education:
(i.e., curriculum developement, curriculum adoption, assessment development, professional development)

Have you participated in other extensive professional development workshops or activities? If so, indicate when and where and give a brief description.

Have you made any science education presentations at state, regional, or national conferences in the past five years?

  Yes

  No

(If yes, please specify)

Describe the extent to which you have previosly studied biodiversity and/or microbiology and what aspects of it you would like to be teaching.

What about biodiversity and microbiology do you want to learn?

In the New York City Commuter Institute , you will engage in scientific inquiry and explore the possibilities and implications of this approach. Please describe how you currently engage students in scientific inquiry in your own classroom.

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