* Required

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* 1. Surname
e.g. Smith, García, Kowalski, Silva, Müller...

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* 2. First Name
e.g. Diana, Albert, Maria, Susanna, John, Laura...

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* 3. Email address
Please make sure you write your email address correctly

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* 4. Country where you teach

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* 5. Please choose if you would prefer to be join the project as an Ambassador or Deputy Ambassador. If you would be interested in either position, please select both. Please be as flexible as possible to increase your chances of being selected.

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* 6. City where you teach

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* 7. Name of your school
(If not teaching at the moment, please write: "n/a" and add the name of the organization you work at e.g. "n/a science museum")

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* 8. Postal address of your school
Please write the full postal address of your school. For example:
European Schoolnet, Rue de Treves 61, 1040, Brussels, Belgium

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* 9. Are you part of the Scientix community already?

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* 10. Subjects you teach

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* 11. Age of your students
Select all the relevant ages. If not teaching any longer, choose the ages of students you have taught in the past.

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* 12. Give us one reason why you would like to be part of this project

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* 13. Give us three reasons why you think you should you be selected to be a Scientix Ambassador / Deputy Ambassador for your country.
Include experience (eg. projects done, research, experience in other European projects, experience with projects' quality assurance, experience presenting at conferences, outreach / networks of teachers known/available for you...)

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* 14. Do you feel confident you would be able to carry out all the tasks planned for the Scientix Ambassadors and Deputy Ambassadors?
Please explain why/how.

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* 15. Name three NATIONAL, REGIONAL or LOCAL teachers’ events where you have participated in the past.
Please try to include URLs, number of attendees and other relevant information

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* 16. All Scientix ambassadors and deputy ambassadors will have to join one of the following two workshops in Brussels. Please select which date or dates are you available. Please note that we must have all ambassadors from a given country attending the same workshop, so please be as flexible as possible to increase your chances of being selected.

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* 17. Please answer yes / no

  Yes No
I agree with the tasks and conditions of being a Scientix Ambassador / Deputy Ambassador
The school management board has agreed to support my work in the Scientix project, if I am selected
Whether I am selected or not, European Schoolnet may contact me for other projects / events
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