DIMACS Connect Institute 2003
APPLICATION FORM
The DIMACS Connect Institute program running July 13 to August 1, 2003, with an optional 2 week
follow up in Summer 2004, will be held at Rutgers University in Piscataway, New Jersey. Participants
must have e-mail access from May 2003 through August 2004.
Checklist:
1. Application form
2. Statement of Understanding (2 pages) - signed by applicant and school principal.
3. Two Letters of Recommendation. One from the school principal and one from the
curriculum supervisor or department chair.
Although these items may be mailed separately, only complete application files will be reviewed.
Deadline for submitting all documents is March 1, 2003.
Early Acceptance deadline is December 13, 2002.
CONTACT INFORMATION
Name:
E-mail (mandatory):
Social Security # (mandatory):
School:
Address:
City:
Phone:
Fax:
Home address:
City:
Phone:
Fax:
State:
Zip:
State:
Zip:
Names of those writing letters of recommendation:
Principal:
Supervisor or Dept. Chair:
School type: Public__ Private__ Rural__ Suburban__ Urban__ Magnet/Special Topic__
Comprehensive__ Comments:
Where did you find out about the DCI Program? (Please be as specific as you can.)
AFFIRMATIVE ACTION INFORMATION
(optional)
Gender: Male__ Female__
Race or ethnic background: ___________________________
EDUCATION
Undergraduate degree:
Major:
Minor:
Year received:
Graduate degree(s) or certification:
Graduate courses taken:
Year received:
Is your school participating in any NSF Curriculum Programs?
Have you participated in other NSF enrichment workshops or programs for teachers? Please give
month/year(s) that you attended.
PROFESSIONAL EXPERIENCE
Please answer all which apply (attach additional pages if necessary)
Classroom teacher (list grade levels and the number of years for each):
Math or computer science supervisor (list number of years):
Other (describe and list number of years):
List the courses that you have taught in school:
List the courses that you will be teaching in the next academic year:
Please describe briefly any leadership roles that you have had in your school or district in the last few
years (curriculum development, Math or Computer Science Club(s), conference organization, districtwide presentations, talks, etc.).
COMPUTING EXPERIENCE
(Please note that participants will use PC’s in the computer labs at DIMACS.)
Describe how you've used computers in mathematics classes:
How frequently do you check your email:
YOUR POTENTIAL CONTRIBUTIONS TO THE PROGRAM
Why do you want to attend this program:
What can you bring to this program to add to the experience for other participants:
APPLICATION FOR TRAVEL SCHOLARSHIPS
A limited number of Travel Scholarships are available for participants who have a financial need.
(Limit up to $150.)
Are you applying for a travel scholarship? Yes___ No___
How much support are you applying for:
Please explain your need for such a scholarship:
ROOMING PREFERENCES
If accepted into the program, what would be your preference for a roommate during the program:
Fellow Teacher ___ Research Program Participant ___