Partner Application for Climate Earthlabs

Please fill out the following form.

Personal Information:

First Name:

Last Name:

Street Address:

City:

State:
Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:

Home Phone:

Cell Phone:

Home Email:

How did you find out about this opportunity?


Completion of the questions about gender and race is helpful for reporting statistics to our funders, but is voluntary.

Gender:

female
male

Race:

African American
Asian
Caucasian
Latino/Hispanic
Other

If Other, please describe:


Professional Preparation:

Undergraduate Degree Major(s):

Graduate Degree Major(s):



Technology Access:
Do you have an Internet-connected computer available for your personal use?
Yes, at home.
Yes, in my classroom.

Information about the school where you teach (2012-13 School Year):

School Name:

School Address:

City:

State:
Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:


School Phone:

Fax:


Your Email at School:


School Principal's Name:

School Principal's Email:


School Science Coordinator's Name:

School Science Coordinator's Email:


Number of years you have been teaching.



Teaching Information (2011-2012 school year):

Subject(s):
Earth Science
Environmental Science
Please list other subjects here:


Grade(s) you taught in 2011-2012.



Teaching Information (2012-2013 school year):

Subject(s):
Earth Science
Environmental Science
Please list other subjects here:


Grade(s) you will be teaching:


Anticipated number of students you will be teaching:



Please indicate which Earthlabs module(s) you plan to teach (2012-2013 school year):

Module(s):
Climate & the Cryosphere
Climate, Weather, & the Biosphere
Climate & the Carbon Cycle


School District Information:
Part of the Earthlabs project involves collecting data from students to help evaluate the efficacy of the curriculum modules. Use of this data by project researchers requires the prior permission of participating students' parents or guardians, the school principal, and frequently someone from the District's Administrative Office.

School District:


Name of School District Superintendent:


Superintendent's Office Phone Number:


District Science Coordinator:

District Science Coordinator Email:



Other info:
Use the box below for any other information you'd like to include with your application.

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.