Research Experience for Teachers Application
Summer 2010 RET Dates June 28-July 30
Application Deadline May 20, 2010
Please type or print legibly in black ink
PERSONAL INFORMATION
Name ______________________________________________________________________________________________________
Last
First
Middle
Home Street Address __________________________________________________________________________________________
Apt # __________________ City ______________________________ State _________________ Zip Code ___________________
Home Phone (______) _________
Cell Phone (_________) __________
E-mail: __________________________________
THIS PROGRAM IS RESTRICTED TO U.S. CITIZENS AND PERMANENT RESIDENTS ONLY.
Gender □ Male
□ Female
Citizenship
Race/Ethnicity (Check no more than two that apply):
□ African American
□ Pacific Islander
□ U.S Citizen
□ Permanent Resident
□ Other___________________
□ American/Native Indian
□ Asian American
□ Hispanic/Latino
□ White
□ Other (please specify)_________________________________________________
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______________________________
The community in which you teach is best described as:
□ Rural
□ Suburban
□ Small Urban (population 100,000-500,000) □ Large Urban (population over 500,000)
Please estimate the composition of the student population served by your school:
____% African American
____% American Indian
____% Hispanic
____% Pacific Islander
____% Asian American
____% White
Recommendations:
Please request two letters of recommendation from individuals familiar with you and your professional
experience. One of the two MUST be from either your principal or department chair. The letters of recommendation should be
sent directly to the address below. Indicate their names, email and mailing addresses here:
1. Name, Address, & Email:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
2. Name Address, & Email:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
PARTICIPANT’S EDUCATION
Undergraduate Institution ______________________________________________________________________________________
City ____________________________________________
State ______________
Undergraduate Major/Minor _____________________________________________ Degree_____________
Year ________
Graduate Institution(s) ____________________________________________________________________________________
City ____________________________________________
State ______________
Graduate Major/Specialization ___________________________________________ Degree_____________
Year ________
Transcripts:
Please have official transcripts for your most recent undergraduate/graduate work sent directly to the address
below. Transcripts have been requested from:
University/College
Dates Attended
No./Credits
Major/Focus
Est. GPA(based on 4.0 scale)
________________________________________________________________
______________________________________________________________________________________________________
TEACHING EXPERIENCE
Number of years teaching Science/Math __________________________________________________________________________
Currently Teach
□ College
□ High School
□ Middle School
□ Elementary School □ Kindergarten
Grade levels and subjects taught (please list all) ___________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Required Statement of Purpose: Attach a 1-2 page typewritten “Statement of Purpose.” Include each of the following:
(1) Brief description of your academic background, education, career objectives, and any prior research experience; (2) state your
reasons for applying to this program and how you and your students might benefit; and (3) provide your area of research interest,
including subject matter and any potential topics or ideas that you have.
How did you hear about this program? ____________________________________________________________________________
SIGNATURE OF APPLICANT _______________________________________________________ DATE ________________
University of Virginia – School of Engineering & Applied Science
Center for Diversity in Engineering, ATTN: RET
P.O. Box 400255 Charlottesville, VA 22904-4255
EMAIL: TRAIL@VIRGINIA.EDU | FAX: 434-924-7774