CENTER for DIVERSITY in ENGINEERING
2011 INNOVATION: Teaching Nanotechnology
within Virginia Standards of Learning
February 11-12 Workshop Application
Application Deadline January 28, 2011
Please type or print legibly in black ink.
Participants will receive UVA Course Credit (1 Cr. Hour), and with prior approval from participant’s
Principal or Staff Development Officer, this credit may be used as 30 Recertification Points.
Participants are requested to attend both the Friday dinner session and the full-day Saturday workshop, if at all possible. Additional
post-workshop assignments may be given in order to qualify for the Recertification Points, if a participant in unable to attend the
Friday dinner session. Full-day attendance on Saturday is mandatory.
I will attend:
□ Friday Dinner & Opening Session, February 11
□ Saturday Full-day Workshop, February 12
□ Yes □ No
I need accommodation on Friday night, at Hampton Inn At the University:
I would be willing to share a room with the following fellow attendee: ______________________________________________
PERSONAL INFORMATION
Name ______________________________________________________________________________________________________
Last
First
Middle
Home Street Address __________________________________________________________________________________________
Apt # __________________ City ______________________________ State _________________ Zip Code ___________________
Home Phone (______) _________
Gender
□ Male
□ Female
Cell Phone (_________) __________
Citizenship
□ U.S Citizen
E-mail: __________________________________
□ Permanent Resident
□ Other___________________
Race/Ethnicity (Check no more than two that apply)
□ African American
□ American/Native Indian
□ Asian American
□ Hispanic/Latino
□ Pacific Islander
□ White
□ Other (please specify) ______________________________________________________________________
PARTICIPANT’S EDUCATION
Undergraduate Institution ______________________________________________________________________________________
City ____________________________________________
State ______________
Undergraduate Major/Minor _____________________________________________ Degree_____________
Year ________
Graduate Institution ____________________________________________________________________________________
City ____________________________________________
State ______________
Graduate Major/Specialization ___________________________________________ Degree_____________
Year ________
SCHOOL INFORMATION
School Name ________________________________________________________________________________________________
School Address ______________________________________________________________________________________________
City _____________________________ State ________________________________ Zip Code ___________________________
District __________________________________________
County _____________________________________________
School Telephone (______) __________________________
School Fax (______) __________________________________
School Email ________________________________________________________________________________________________
Type of School
□ Public School □ Private School □ Community College
□ Other (please specify) ______________________________________________________________________
The community in which you teach can be best described as:
□ Rural
□ Suburban
□ Small Urban (population 100,000-500,000) □ Large Urban (population over 500,000)
Please provide the estimated composition of the student population attending your school:
____% African American
____% American Indian
____% Hispanic
____% Pacific Islander
____% Asian American
____% White
TEACHING EXPERIENCE
Number of years teaching Science/Math/STEM ___________________________________________________________________
Currently Teach
□ College
□ High School
□ Middle School
□ Elementary School
□ Kindergarten
Grade levels and subjects taught in the last three years (please list all) ________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Required Statement of Purpose:
Please attach a one-page maximum “Statement of Purpose” that describes why you are interested in this workshop and how
you and your students might benefit.
As a participant, I agree to:
1) Permit publication of any original work produced as a part of this workshop (including lessons) in any format.
2) Permit photos of myself taken during the workshop to be used in publications and electronic media, with my name.
SIGNATURE OF APPLICANT _______________________________________________________ DATE ________________
SEND COMPLETED APPLICATION PACKET NO LATER THAN JANUARY 28, 2011 BY EMAIL, FAX, OR MAIL TO:
UNIVERSITY OF VIRGINIA / CENTER FOR DIVERSITY IN ENGINEERING
ATTN: 2011 INNOVATION: TEACHING NANOTECHNOLOGY WORKSHOP
PO BOX 400255
CHARLOTTESVILLE, VA 22904-4255
EMAIL TO: TRAIL@VIRGINIA.EDU | FAX TO: 434-924-7774