BGSU

June 17 to June 30, 1999

(Please feel free to print a copy of application)

Science Goes to the Movies

Teacher Application Form

Name:

Social Security #:

E-mail address:

Home address:

Zip:

Tel #:

School address:

Zip:

Tel #:

School District:

Teaching Responsibility

grades: 6 7 8 9 10 11 12

Subjects:

chemistry physics

life science comprehensive science

earth science environmental science

physical science other (please explain)

Are 10% or more of your students from underrepresented groups? yes no

Have you ever enrolled in graduate courses at BGSU? yes no

Are you requesting on-campus housing for seven nights? yes no

Have you ever attended a workshop on the BGSU campus? yes no

if so, which one(s):

List colleges attended , degrees held, and dates:

What is your comfort level with computer technology?

Not very experienced but willing to learn

Some experience with computer multimedia technologies

Well-versed in computer technology and looking for new applications

Please give a brief statementof your reasons for wanting to attend this workshop and your anticipated use

of this subject next year