FIU Modeling Instruction Workshop Application-Summer 2012
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1. Personal Information

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1. Please provide your contact information

Please provide your contact information First Name:
Last Name:
Home Address:
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Email Address (home):
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2. Cell Phone:

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3. Please provide your school information

Please provide your school information School:
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4. Not all applicants will be selected as project participants. Selection will not discriminate on the basis of race, color, religion, gender, national origin, or disability. If selected to participate in the CHEPREO Modeling Project, the participant authorizes the release of program application materials as well the release of video tape, audio tape, photographs, questionnaire responses, or any other materials for use in program development, research publications, or project promotion.


Please indicate your status (for statistical purposes)	Not all applicants will be selected as project participants. Selection will not discriminate on the basis of race, color, religion, gender, national origin, or disability. If selected to participate in the CHEPREO Modeling Project, the participant authorizes the release of program application materials as well the release of video tape, audio tape, photographs, questionnaire responses, or any other materials for use in program development, research publications, or project promotion. Please indicate your status (for statistical purposes)

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