Personal Data
Title:
Mr
Ms
Mrs
Dr
First Name:
Last Name:
Preferred Phone* :
Preferred Email* :
* To contact you with questions and/or notifications.
High School Name:
High School Address:
High School Address 2:
City:
State:
Zip Code:
Work Phone 1:
Work Phone 2:
Work Fax:
Work Email 1:
Work Email 2:
Home Street Address:
Street Address (cont.):
City:
State:
Zip Code:
Home Phone 1:
Home Phone 2/Cell:
Home Email 1:
Home Email 2:
Please check your gender:
Please check the group that best describes your ethnical/racial status:
Please check your age group:
Approx. percentage of minority students at your institution: Approx. percentage of students on lunch assistance in your school is: Approx. percentage of minority students in your biology classes:
Additional Information (Does not affect selection )
How did you find out about this workshop?
DNALC email DNALC direct mail On the DNALC Internet site At a convention or trade show Link from an Internet site Internet search Word of mouth During a visit to the DNALC in Cold Spring Harbor Through InnovATEBIO Through the QUBES Nanopore Network From Oxford Nanopore or Oxford Nanopore Education Beta Program Through a supply or equipment company (such as Carolina Biological Supply Company) Other (please specify)
I have previously attended a DNALC, CyVerse, InnovATEBIO, or IUSE workshop:
(Please specify year and title)
I will require housing during the symposium:
Undergraduate degree and major: Graduate degrees and subject areas: Years teaching high school: Additional training (specify): List names and grade levels of courses you are currently teaching: List names and grade levels of courses you have taught in the previous two school years: Describe any special school positions or responsibilities: Describe any involvement with professional associations at the local, state, and/or national levels: Give title, grade level, number of students instructed, and brief description of any course(s) or unit(s) in genetics/biotechnology you have taught in the last two years: List facilities and equipment available at your school for genetics/biotechnology instruction. If equipment is available through a resource-sharing consortium, provide information on its organization and users: Beginning with the most recent and working backward, provide brief descriptions of up to five specialized training courses, research experiences, or curriculum development projects in which you have participated that focused on genetics, molecular genetics, human genetics, or biochemistry. For each activity provide year, program name, sponsoring organization, instructor or mentor, and duration/time spent: Beginning with the most recent and working backward, document up to five teacher-training activities or presentations in any field of biology for which you have been a primary instructor, presenter, or organizer. For each activity provide year, name/description of activity or program, sponsoring organization, your responsibility, and duration/time spent: List any articles, papers, or curriculum materials you have written on education in genetics, molecular genetics, human genetics, or biochemistry: Describe an implementation plan that proposes how you intend to merge your special teaching experience, available school resources, community partnerships, and local curriculum to fulfill a role as a regional genetics education resource person. Outline specific in-service activities that could be reasonably supplied to elementary and secondary teachers in the region. Do not exceed 1000 words:
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