ACM Pedagogic Resources > ACM/FaCE > Projects > Earth and the Environment in Italy > Workshop Registration

Workshop Registration Form

Registration deadline: February, 10, 2010

Complete the following form and click on SUBMIT to confirm your registration. Be sure to hit the SUBMIT button before leaving this page or your information will be lost. We encourage you to compose your answers to the longer questions in a word processor and to cut and paste the resulting text into this form.

Contact Information
First Name:

Last Name:

Department:

Institution:

Address:

City:

Select a State:

Zip Code:

Phone:

FAX:

Email Address:

Confirm Email Address:

(Please Note: Your email address is what we use to track your application and participation in the workshop. Be sure to use the same email address in all forms relating to your workshop participation. This email will also be our primary means of communication with you.)

Question SetBriefly describe your interest in attending this workshop.

Do you currently teach courses in, or cross-listed with Geology or Environmental Studies/Science? If so, please list course numbers and titles.

Does your institution offer an off-campus studies program related to Earth and/or Environmental Studies/Science? Please include geology field camps.

Finally, if we are successful in getting an ACM sponsored Earth and The Environment Fall semester program going at OGC, would you be interested (and able!) to direct the program at some point in the next five years?

DemographicsGender:

Male
Female

Ethnicity (choose one):

Hispanic or Latino
Not Hispanic or Latino

Race (select one or more):
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Disability status (select one or more):
Hearing Impairment
Visual Impairment
Mobility/Orthopedic Impairment
Other
None

Citizenship (choose one):

U.S. Citizen
Permanent Resident
Other non-U.S. Citizen

Number of years of full-time teaching experience:

Number of years teaching at the college level:

Current position:

Discipline:

or Other discipline:

Will you teach next fall at an institution that serves a large number of minority students?:

Yes
No

Which of the following best describes the department or program in which you will teach next fall:

Two year college (Associate is the highest degree)
Private four-year primarily undergraduate (BS or BA is the highest degree)
Public four-year primarily undergraduate (BS or BA is the highest degree)
Masters granting (MS is the highest degree)
Doctoral granting (PhD is the highest degree)

How did you learn about this workshop?
If there is other information relevant to your application, please let us know here:

AccommodationsDo you have a disability, food allergy, or preference that requires accommodation at the workshop? If so please describe:

Workshop Product Release

In confirming my registration for this workshop, I agree that any audio recording or images (still or video) made of me during the workshop may be used on the project website, in printed project publications, and in materials developed by the project. I further agree that my contributions to creative works that emerge from workshop activities (e.g., discussions on the listserv, contributions to the web page, summaries of group discussion, etc.) may be used by the PIs and conveners for development of future workshop materials, for scholarly reports, and for promotion of the workshop series. Attribution for original contributions will be made whenever possible.

Name Email *Please type the two distorted words into the box below. Separate them with a space. This helps us prevent spam. For more details or help click the question mark.

« Previous Page Next Page »

ACM Pedagogic Resources