Please fill out all sections completely in PRINT. Honoraria will be mailed to home address.

Date

(Name should be as shown on Social Security Card.)

Mr Mrs Ms Dr Last Name First Name Middle
 

Social Security Number**

School Name and District

School Mailing Address

School Phone 

School Fax Number 

Home Mailing Address

Home Phone 

Home Fax Number 

Primary E-Mail

Grade(s) you teach:

Subjects:

Name of Workshop(s) You Wish to Attend and Date(s) of Workshop:

Choice 1. 

Choice 2. 

Choice 3.

Do you have any comments or questions?

**You may enter zeroes and call in your SSN to Linda Taylor at 817-257-7698 if desired.

If you are unable to use the on-line registration, you may mail or fax the application. You may also email the required information to Linda Taylor.

Mail Form(s) to: Linda Taylor, Institute of Mathematics, Science and Technology Education, Texas Christian University, TCU Box 297920, Fort Worth, TX 76129.

Fax Form(s) to: Linda Taylor, School of Education, (817)257-5525

Note:

Registration for workshops is limited. Submitting this application form does not guarantee a place in the workshop(s) you listed above. You will receive a confirmation of registration listing the workshop(s) for which you registered. If you have not received a confirmation by the date of the workshop you wish to attend, the workshop has been closed. Please, only attend the workshop(s) for which you have received a registration confirmation.

You will receive a Continuing Professional Education (CPE) Activity Certificate for each workshop attended.  Each participant is eligible for one honorarium.  Your CPE certificate will be faxed to your school as soon as possible, but it requires several signatures and this may slow the process.

Last updated: 09 September 2003/lht
Copyright © 2000 Texas Christian University