The Engineering Process ENG5100 Participant Application You must complete a participation form and apply for admission to Michigan Tech. Michigan science teachers will be given first preference. $300 (includes room and board) for participants who have a valid teaching certificate from the State of Michigan. Non-Michigan teachers will be charged a reduced tuition/administrative fee of $950 (does not include room and board). Please type or print in ink. Duplicate as needed. Name__________________________________________________________________________________________ First Middle Last Home address_________________________________________________________________________________________ Street City State ZIP Date of birth__________________________ MTU M # (if you are a current or former student at MTU)_____________ Home phone ( Fax ( )_________________________________ Work phone ( )____________________________ )___________________________________ Work email_______________________________________ How often do you check your email?________________ Home email______________________________________ School name___________________________________________________________________________________ School address_________________________________________________________________________________ Street City State ZIP Current subject areas taught_______________________________________________________________________ Grades taught___________________________________________________________________________________ School District__________________________________________________________________________________ Degree earned/areas of certification__________________________________________________________________ Have you taken courses previously at Michigan Technological University? Yes_____ No_____ I plan to take this course for: □ Non-degree seeking credit (i.e. for permanent teacher certification renewal) □ Currently enrolled in a graduate program at MTU □ Currently enrolled in a graduate program at another university I agree to all of the following to participate in the Engineering Process Course ENG5100. 1) 2) 3) 4) 5) 6) 7) Read and respond to all preparatory materials and communications prior to the course. Consent to the release of my name, address, and email address to other participants in the course. Fully participate in each day of the course. Meet the requirements of the syllabus for the course. Understand that my final project may be published in some form. Consent to the release of my photograph for publications. My written work submitted in the courses may be used for project evaluation. Signature_________________________________________________________________Date__________________ Return your completed application by May 20th, 2016 along with the reduced tuition payment and administrative fee to: Teacher Professional Development Coordinator Cognitive and Learning Sciences Michigan Technological University 1400 Townsend Drive Houghton, MI 49931-1295 Telephone: 906-487-2460 E-mail: [email protected] Applicants who are not selected for participation will be refunded as soon as selection decisions have been made. http://www.mtu.edu/cls/education/development/institutes/ *Costs have been reduced through the generous support of the Department of Cognitive and Learning Sciences to lower official MTU tuition for teachers with proof of current teacher certification (2015/2016 Official Applied Science Education Graduate Resident and Non-Resident is $561.00 per credit).