1 - Last Name:
Required

2 - First Name & Middle Initial:
Required

3 - Home Address (street, city, state, zip code, country)
Required

4 - Home phone: (area code & phone number)

Required

5 - Home email address:

Required

6 - Name of school where you teach:

Required

7 - School Address (street, city, state, zip code, country)

Required

8 - Your school number where we may reach you. (area code & number)

Required

9 - Your email address at your school

Required

10 - Current teaching assignment (grade levels and courses, e.g., physical sciences (9))

Required

11 - Number of years teaching this level

Required

12 - Total number of years you've been teaching

Required

13 - Other grade levels or subjects that you have taught

14.
Certification Status (click one)

Follow these links for details about certification:
http://www.k12.wa.us/certification/teacher/limited2.aspx
http://www.k12.wa.us/certification/teacher/teachercertificatetypes.aspx
http://www.k12.wa.us/certification/teacher/initial.aspx

	No certificate
	Limited Certificate (Emergency, Conditional, Transitional
	Residency/Professional, Initial/Standard, Continuing, Provisional, or Equivalent

15.
For more information about National Board certification, please follow this link http://www.nbpts.org/

	Yes	No
Do you hold a National Board for Professional Teaching Standards certificate?
Are you currently working toward a National Board for Professional Teaching Standards certificate?
Are you interested in pursuing a National Board for Professional Teaching Standards certificate?

16.
What endorsements do you currently hold?

	Biology
	Earth Science
	Chemistry
	Physics
	Mathematics
	Middle Level Math/Science
	Other, please specify:

17.
What endorsements are you working on?

	Biology
	Earth Science
	Chemistry
	Physics
	Mathematics
	Middle Level Math/Science
	Other Future Endorsements, please specify:

18.
What are some outcomes you hope to gain from this summer institute?

19.
How does your participation in this institute align with your professional goals?

20.
With what textbooks and/or curricula have you had experience in the classroom?

21.
Please list any workshops, conferences or professional development training in science education you have attended in the past.

22.
The academic-year follow-up sessions are a key component of this program. These sessions may be scheduled after school monthly (from 4-7 PM), Saturdays (about 3 times throughout the year), or on school days with sub release. Total numbers of session hours offered will be about 50 for the academic year 2009-2010. Teachers will be strongly encouraged to participate in at least 80% of the hours offered in these sessions. Can you commit to this?

Yes No

23.
From the previous . Please express your preference, if any, for different schedules of follow-up sessions (after school, Saturdays, sub release, etc.). If you cannot commit, please explain.