NanoDays 2014 - Teacher Workshop

Registration Form

Thank you for your interest in attending the NanoDays Nanotechnology Teacher Workshop!

Please mark your calendar...

NanoDays 2014 - Nanotechnology Teacher Workshop
Date: Tuesday, May 6, 2014
Time: 8:00AM - 4:00PM
Location: Millennium Science Complex

Attendance is FREE to all participants.
Space is limited - a "wait-list" will be created once slots are filled.

Note: Some of the information requested below will be used for evaluation purposes and future program improvement. Your responses are greatly appreciated - thank you!

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1. Please provide your contact information below:

Note: This information will be used for name-tags, possible mailing of program materials, and direct communication if necessary to contact you. Please use your mailing address and type your name exactly as you would like to have it printed.

First Name:* *

Last Name:* *

Mailing Address Line 1: *

Address Line 2 (if needed):

City/Town: *

State: *

ZIP: *

Email Address: *

Phone Number: *

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2. If currently employed as a full time teacher, please write the name of your school.
Otherwise, please leave blank.

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3. If currently employed by a school district in any way, please write the name of your district.
Otherwise, please leave blank.

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4. PDE Number (if interested in receiving ACT 48 Credit - there is a $10 fee which can be paid at check-in).
Otherwise, please leave blank.

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5. Grade Levels: Which one of the following best describes the current grade level(s) of the students you teach?

Upper Elementary (Grades 4-6)

Middle School or Junior High (Grades 6-8)

High School (Grades 9-12)

Other (please describe):

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6. Educational Role: Which one of the following best describes your current position?

Classroom Teacher

Substitute Teacher

Home Schooler

Administrator/Supervisor

Outreach Provider

Curriculum Supervisor

Informal Educator

University Faculty/Staff

Other (please describe):

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7. Subject Areas: Which of the following best describes the subject area(s) that you teach?
(choose all that apply)

Astronomy

Biology

Chemistry

Earth Science

Engineering

Environmental Education

General Science

Mathematics

Physical Science

Phyisics

Social Studies/Geography

Space Science

Technology Education

Other (please specify)

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8. How did you hear about the NanoDays Teacher Workshop opportunity?

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9. What is your primary reason for attending the Nanotechnology Teacher Workshop? (please briefly describe)

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10. At its conclusion, what would you like to have gained as a result of attending the Nanotechnology Teacher Workishop? (please briefly describe)

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11. Lunch will be provided. If you have any dietary restrictions, please briefly describe them here so that we can do our best to accommodate your needs.
Otherwise, please leave blank.

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12. Please read and confirm your agreement to the following:
I understand that there is no fee to attend this workshop, but that space is limited and a wait list will be created once positions are filled. I also realize that program organizers need an accurate account of attendees for planning purposes. Therefore, if admitted to the program, I am committed to attending. If for some reason my circumstances would change, I promise to inform program organizers immediately so that another person can be admitted in my place.

I agree and will attend if admitted to the program.

I am not yet able to guarantee my attendance if admitted to the program.

Other (please explain):

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13. Optional: For reporting purposes, you are invited to provide the following information:
What is your gender?

Male

Female

I prefer not to report

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14. Optional: For our reporting purposes, you are invited to provide the following information:
Which one of the following best describes your ethnicity?

Black or African American

Asian

White or Caucasian

Native American or Alaskan Native

Pacific Islander

Hispanic or Latino

I prefer not to report

Other (please specify)

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1. Please provide your contact information below:Note: This information will be used for name-tags, possible mailing of program materials, and direct communication if necessary to contact you. Please use your mailing address and type your name exactly as you would like to have it printed.

Question Title

2. If currently employed as a full time teacher, please write the name of your school. Otherwise, please leave blank.

Question Title

3. If currently employed by a school district in any way, please write the name of your district. Otherwise, please leave blank.

Question Title

4. PDE Number (if interested in receiving ACT 48 Credit - there is a $10 fee which can be paid at check-in). Otherwise, please leave blank.

Question Title

5. Grade Levels: Which one of the following best describes the current grade level(s) of the students you teach?

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6. Educational Role: Which one of the following best describes your current position?

Question Title

7. Subject Areas: Which of the following best describes the subject area(s) that you teach? (choose all that apply)

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8. How did you hear about the NanoDays Teacher Workshop opportunity?

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9. What is your primary reason for attending the Nanotechnology Teacher Workshop? (please briefly describe)

Question Title

10. At its conclusion, what would you like to have gained as a result of attending the Nanotechnology Teacher Workishop? (please briefly describe)

Question Title

11. Lunch will be provided. If you have any dietary restrictions, please briefly describe them here so that we can do our best to accommodate your needs. Otherwise, please leave blank.

Question Title

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13. Optional: For reporting purposes, you are invited to provide the following information:What is your gender?

Question Title

14. Optional: For our reporting purposes, you are invited to provide the following information:Which one of the following best describes your ethnicity?

1. Please provide your contact information below:

Note: This information will be used for name-tags, possible mailing of program materials, and direct communication if necessary to contact you. Please use your mailing address and type your name exactly as you would like to have it printed.

2. If currently employed as a full time teacher, please write the name of your school.
Otherwise, please leave blank.

3. If currently employed by a school district in any way, please write the name of your district.
Otherwise, please leave blank.

4. PDE Number (if interested in receiving ACT 48 Credit - there is a $10 fee which can be paid at check-in).
Otherwise, please leave blank.

7. Subject Areas: Which of the following best describes the subject area(s) that you teach?
(choose all that apply)

11. Lunch will be provided. If you have any dietary restrictions, please briefly describe them here so that we can do our best to accommodate your needs.
Otherwise, please leave blank.

13. Optional: For reporting purposes, you are invited to provide the following information:
What is your gender?

14. Optional: For our reporting purposes, you are invited to provide the following information:
Which one of the following best describes your ethnicity?