Due to the sensitive information on the application, please use your browsers print function, to print the page, fill it out and send it back. Or if you perfer you may send the required information by e-mail through the e-mail link below.

1. NAME:

2. SCHOOL:

3. SCHOOL ADDRESS:

4. CITY/STATE/ZIP:

5. PHONE:

6. HOME ADDRESS:

7. CITY/STATE/ZIP:

8. HOME PHONE NUMBER:

9. What subjects and grades do you normally teach?

10. Why are you interested in taking this workshop?

11. What is your chemistry background? (i.e. what courses, workshops, have you participated in?)

12. What types of hands on experiments do you do in your classroom?

13. How do you think you will use the information you will receive in your classroom?

14. What types of facilities do you have available in your classroom for hands on experimentation? (i.e. access to a natural gas line, chemicals, etc?)

15. Will other teachers from your school be applying for this in-service? (If yes how many and who are they?)

16. All teachers must attend the in-service July 10 through July 21 2000.

17. Name and phone number of your school principal. Please Print.

If you wish to attend the inservice please fill in an application and mail it to the following address:

Sharon Lee McCarthy, Ph. D.
Department of Chemistry and Physics
Chicago State University
9501 S. King Drive
Chicago, Il 60629
773-995-2810
e-mail