MIT Science and Engineering Program for Teachers Application Form

                                                                                                                        1/14/05

Completed form should be e-mailed to: MITSEPT2005App@att.net,

OR, printed and mailed to:
MIT Club of PS SEPT Applications

c/o CCC

P. O. Box 356

Mercer Island, WA 98040

Deadline for submission of applications is March 7, 2005.  We recommend requesting the brochure about the program directly from MIT.  NOTE: this application supercedes the application enclosed with that package. 

The applications that we select for scholarship aid will be forwarded to MIT along with our recommendation for admittance.  NOTE: please rename the e-mailed form with your name. 

A. Your Information -----------------------------------------------------------------------------

1) NAME (Last, first middle initial):

2) STREET ADDRESS:

3) CITY STATE ZIP:

4) HOME PHONE:

5) E-MAIL ADDRESS:

6) GRADE(S) & SUBJECT(S) TAUGHT:

B. School Information ---------------------------------------------------------------------------

1) SCHOOL NAME:

2) ADDRESS:

3) CITY STATE ZIP:

4) WORK PHONE:

5) WORK E-MAIL:

C. Your Education --------------------------------------------------------------------------------

1) COLLEGE OR UNIVERSITY:  

            MAJOR FIELD:

            DATES ATTENDED:

            DEGREE AND DATE:

2) COLLEGE OR UNIVERSITY:

            MAJOR FIELD:

            DATES ATTENDED:

            DEGREE AND DATE:

3) LIST MEMBERSHIP IN PROFESSIONAL ORGANIZATIONS:

4) LIST HONORS AND AWARDS:

5) PROFESSIONAL DEVELOPMENT COURSES PREVIOUSLY ATTENDED:

D. General --------------------------------------------------------------------------------------------

1) LIST EXTRACURRICULAR ACTIVITIES FOR STUDENTS THAT YOU LEAD OR PARTICIPATE IN AND THE BENEFITS STUDENTS RECEIVE:

2) DESCRIBE YOUR TEACHING EXPERIENCES AND HOW THEY MIGHT DISTINGUISH YOU FROM YOUR COLLEAGUES:

3) WHY IS IT IMPORTANT TO YOU TO ATTEND MIT'S SCIENCE AND ENGINEERING PROGRAM (SEPT) FOR TEACHERS?

4) HOW DID YOU HEAR ABOUT THE PROGRAM?  (IF YOU WERE REFERRED BY AN MIT CLUB MEMBER, PLEASE GIVE THEIR NAME.)

5) PLEASE INCLUDE ANY ADDITIONAL INFORMATION YOU THINK WOULD HELP THE COMMITTEE IN MAKING A DECISION ABOUT YOUR APPLICATION

Recommendations -------------------------------------------------------------------------

PLEASE SUPPLY THE FOLLOWING INFORMATION FOR THREE PEOPLE WHO ARE FAMILIAR WITH YOUR TEACHING ACTIVITIES AND ASSOCIATED INTERESTS:

NAME:

ADDRESS:

PHONE NUMBER (HOME AND OFFICE):

E-MAIL ADDRESS:

NAME:

ADDRESS:

PHONE NUMBER (HOME AND OFFICE):

E-MAIL ADDRESS:

NAME:

ADDRESS:

PHONE NUMBER (HOME AND OFFICE):

E-MAIL ADDRESS:

THANK YOU FOR YOUR INTEREST -------------------------------------------------------- 

The MIT Club of Puget Sound