First Name:  

Last Name:    

E-mail Address:    

Home Phone Number:    

School Phone Number:  

Home Mailing Address

Street or P.O. Box:

(other):                 

City:                     

State:                            Zip:

School Information

School Name:  

County:           

Division:         

School Mailing Address

Street or P.O. Box:

(other):                 

City:                     

State:                            Zip:

Teaching Experience

What classes and for what grades do you currently teach?

What classes have you taught in the past that you do not teach now?

Briefly describe any astronomy experience that you have. Prior astronomy experience is not required, many of the participants will not have any astronomy experience.

Personal Statement

In 1-2 brief paragraphs, please describe your reasons for participating in this class.
(This textbox area will scroll down if you need more room to type in your statement.)

Additional Information

Where did you hear about our workshop? (brochure from science coordinator, word of mouth, Curry School of Education, UVa website, etc...). This information will help us plan future events!

We have arranged housing, double occupancy, in Charlottesville for July 9-13. There will be no charge for the room and a small stipend will be provided to cover the cost of travel and food. If you prefer single occupancy, you may upgrade to a single room at a cost of about $48 per night.

Will you need a room for the workshop?

YES, I will need housing as I cannot commute each day and would prefer double occupancy (no charge for housing)

YES, I will need housing as I cannot commute each day and would prefer single occupancy (extra charge of about $48 per night for four nights)

NO, I will not need housing as I am able to commute each day