Due Sept. 7, 2007 by 5:00 pm. Please fill out this form carefully and completely. Teachers selected for a free visit will be notified by mail the week of September 17, 2007. Do not print this page to mail or fax. If you would like to mail or fax your form, download our pdf application here.

All fields with an * are required. Please complete all fields.

Your Information
Teacher Name:*	Grade Level:*
Teacher E-mail:*
School:*	%Title 1 students:
School Address:*
City:*	County:*
State:*	Select AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO NT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Other Zip:* School District:
School Phone: *	School Fax:
Home Phone:

Workshops All teachers planning to attend with their class must be listed on the application and attend a teacher workshop prior to their class visit. Select a minimum of three workshops, in order of preference, from the list of teacher workshops. If you have already attended a workshop, indicate the academic year (00-01, 01-02, etc) and your name. (Please indicate any name changes.)

Teacher Name	Workshop Date, Time & Location (if not previously attended)	Grade Level	No. of students
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