Child's : First Name:   MI:   Last Name:

Street Address:

City:   State:   Zip:

Home Phone:   E-Mail:

District:

Name:

Street Address:

City:   State:   Zip:

School Phone:   School Fax:

Graduation Year:

Position: (check most appropriate)
Teacher   Principal   Superintendent
Other (be specific)

School Grade Level: (check all that are appropriate)
Pre-K   Elementary   Middle School   High School   Higher Ed
Other

Grade Level You Teach:
Grade Level: (be specific)

School Type: (check most appropriate)
Public   Private   Substitute   Pre-Service   Higher Ed
Other (be specific)

Expertise: (check all that are appropriate)
Administration   Mathematics   Science   Education
Other

Gender:
Female   Male   Undiscolosed

Ethnicity:
Caucasian   African American   Native American
Asian   Hispanic   Mixed