Application for Participation in Professional Development For Advanced Coursework in STEM

Application for Participation in Professional Development For Coursework in STEM
Once you submit your STEM Application, you will be taken into the Letter of Agreement for the STEM Program. Upon completion of your Letter of Agreement, you will be automatically forwarded to a site where you will be able to register for the summer workshops.
Administrator Referral
Please enter the name of the principal or superintendent that referred you to this application:*
Please enter the email address of the principal or superintendent that referred you to this application:
Kindle Fire Referral Friend (if you were referred by a friend, enter their name here to BOTH win a Kindle Fire)
FRIEND's First Name
FRIEND's Last Name
Applicant Information
First Name*
Last Name*
Full Name*

First NameLast Name
Work Email*
Please enter an email you will access year-round - even during summer months
Personal Email*
Daytime Phone Number*

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
What's the best way to contact you?*

E-mailDaytime Phone Number (during school year)Cell Phone Number (during summer)
Do you give us permission to send text message reminders/updates to your cell phone? (Mobile phone text messaging charges may apply. Please consult your mobile phone service plan.)*

YesNo
District Name*
County of District*
Your region is CAPITAL - please select the CAPITAL region below
Your region is CENTRAL - please select the CENTRAL region below
Your region is LONG ISLAND - please select the LONG ISLAND region below
Your region is LOWER HUDSON VALLEY

UNLESS YOU TEACH IN THE YONKERS PUBLIC SCHOOL DISTRICT. IF YOU TEACH IN THE YONKERS PUBLIC SCHOOL DISTRICT, PLEASE CHOOSE YONKERS AS YOUR REGION.
Your region is MID-HUDSON - please select the MID-HUDSON region below
Your region is MID-SOUTH - please select the MID-SOUTH region below
Your region is MID-STATE UNLESS YOU ARE PART OF THE SYRACUSE CITY SCHOOL DISTRICT
Your region is MID-WEST -

UNLESS YOU TEACH IN THE ROCHESTER CITY SCHOOL DISTRICT. IF YOU TEACH IN THE ROCHESTER CITY SCHOOL DISTRICT, PLEASE CHOOSE ROCHESTER AS YOUR REGION.
Your region is NORTH COUNTRY - please select the NORTH COUNTRY region below
Your region is NYC - please select the NYC region below
If you teach in the Syracuse City School District, then your region is SYRACUSE - please select the SYRACUSE region below
Your region is WEST - please select the WEST region below
Region (choose)
School Name*
School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Teaching Content Area*
Grade Level(s)*

7th8th9th10th11th12th
Education/Background

Degrees/Certifications/Subjects
Education: Check all that apply*

Bachelor's DegreeMaster's DegreeDoctorate Degree
Professional Certifications
Please list any education-related certifications
Additional Credit Hours Earned
ex. 4 hours-English Literature
Teaching Experience
How many years of teaching experience do you have?*
Current Primary Teaching Assignment*
Certification: Please select the primary teaching area in which you are certified.

Not certified in a STEM field (Science, Technology, Engineering, Mathematics)MathematicsTechnology EducationEarth ScienceBiologyChemistryPhysicsOther
If "other" please specify
Current Secondary Teaching Assignment(s)*

Please check all boxes that apply

	This course is offered in my school	This course is offered as Advanced Placement in my school	I teach this course as Advanced Placement in my school	I teach this course but NOT as Advanced Placement in my school
Calculus
Computer Science A
Statistics
Biology
Chemistry
Physics
Environmental Science

Please indicate how the professional development offered by this program will be implemented in your school district:*
Please describe your reasons for wanting to participate in this professional development program. (check all that apply)*

It is required by my schoolI am volunteering to participate in the program to improve my teaching practicesA colleague referred me to the programI will receive compensation for participating in the program
Teachers selected for the program will have the opportunity to attend additional training in how to form and lead vertical team groups as well as training to become an AP consultant. Would you be interested in this opportunity?*

YesNo
Teacher ID Number
Please enter the following information in the fields below
(these fields will become your NYSED STEM Program Teacher ID number)

Last 4 digits of home phone number (ex. 2100) ex.

Birth Month. (ex. January: please select from the drop down box 01)

Birth Date. (ex. January 30: please select from the drop down box 30)
Last 4 digits of home phone number*
Birth Month*
Birth Date*
Please enter the message as it's shown to confirm your application:*
Questions/comments/problems?
Should be Empty:

Application for Participation in Professional Development For Coursework in STEM

Administrator Referral

Kindle Fire Referral Friend (if you were referred by a friend, enter their name here to BOTH win a Kindle Fire)

Applicant Information

Education/Background

Teaching Experience

Teacher ID Number