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Contact Information
First Name *
MI
Last Name *
Preferred Email Address *
Personal Email Address
Work Email Address
Home Address 1 *
Home Address 2
City *
State/Territory *
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Zip Code *
Personal Phone Number *
Team Member(s), if applicable
School Information
School Name *
School Type *
Select School Type
Independent
Parochial
Public
Public Charter
Other (please specify)
If Other, please specify
School District or Affiliation
School Address 1 *
School Address 2
City *
State/Territory *
Select one
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code *
School Phone Number *
School Website
Subject(s) you teach (select all that apply) *
Grade level(s) you teach (select all that apply) *
Total years teaching *
Institute Preferences
First Date Choice *
Select one
Week 1: July 9 – 13, 2012
Week 2: July 30 – August 3, 2012
Second Date Choice *
Select one
Week 1: July 9 – 13, 2012
Week 2: July 30 – August 3, 2012
Not applicable
Tell Us More About Yourself
Describe an interdisciplinary project you took part in teaching and/or planning. What made it challenging? What made it rewarding? *
Describe an innovative lesson you created and taught which you and your students found especially rewarding. *
Tell us more about yourself and why you (and your team, if applicable) are uniquely suited to participate in and contribute to this Institute. *
Which of the following technologies and applications are you currently using for instructional purposes (select all that apply)?
Explain your instructional use of the above technologies and applications.
How did you learn about the Institute (select all that apply)? *
Social Education Teacher Update E-Newsletter (edweek.org)Classroom Connections teacher e-newsletter
Which of the following factor(s) influenced your decision to apply to the Institute (select all that apply)? *
Do you plan to apply for graduate credit offered through George Mason University for your participation in this Institute? *
Select one
Yes
No
Do you anticipate receiving professional development credits through your school or district for your participation in this Institute? *
Select one
Yes
No
Before submitting, be sure that all sections of the application are complete and that you print a copy for your records.
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