MATHEMATICS AND SCIENCE CENTERS
			PROFESSIONAL DEVELOPMENT ACTIVITY
			   PARTICIPANT INFORMATION FORM


PLEASE COMPLETE THE FOLLOWING:


1. DATE: ________________

2. NAME OF ACTIVITY: _____________________________________________________

3. LAST NAME: _________________		FIRST NAME: ______________________

4. MAILING ADDRESS: ______________________________________________________
                       STREET	  	    CITY	  STATE	      ZIP

5. TELEPHONE: ______________

6. FAX: ________________	

7. E-MAIL: __________________________________

8. SCHOOL AND DISTRICT: __________________________________________________

9. GENDER:     _____ FEMALE 		_____ MALE

10. POSITION (Check one):

		___ Pre K Teacher
		___ Elementary Teacher
		___ Mathematics Teacher
		___ Science Teacher
		___ Technology Teacher/Specialist
		___ Combination Math, Science, and/or Technology Teacher
		___ Principal or Building Administrator
		___ Curriculum Director/Resource Specialist
		___ Central or District-Level Administrator
		___ Other  Describe: _____________________________________

11. GRADE LEVEL (Check one):

		___ Pre K
		___ Elementary
		___ Elem & Mid/Jr.High
		___ Middle/Jr. High
		___ Mid/Jr. & HS
		___ High School
		___ Other Mixed Levels

12. ETHNICITY:

		___ African-American	___ Hispanic
		___ Arab-American	___ Native American
		___ Asian-American	___ Mixed Ancestry
		___ Caucasian


Prepared by SAMPI, Western Michigan University, for 2009-2010 use.