Mathematics in Industry Institute for Teachers

Application Form

Center for Industrial Mathematics and Statistics
Department of Mathematical Sciences
Worcester Polytechnic Institute
Worcester, MA 01609

Please fill in all requested information:

1. General Information

Family Name:
First Name:
Middle Initial:
Social Security Number:
Date of Birth:
Country of Citizenship:

2. Address

School Address:  
  School District
  School
  Street
City, State, ZIP
  Telephone
  Email

Permanent Address:  
  Street
City, State, ZIP
  Telephone
  Email

Note: All correspondence will be via e-mail.

3. Ethnicity

Please check all that apply.

African-American American-Indian
Asian-American Chicano
European-American Fillipino
Latino Native Alaskan
Puerto Rican  
Other (please specify)

4. Education

List all degrees you have obtained.

Name of Institution Dates Attended Major

5. Credit

Participants can obtain PDPs or graduate credit for participating in the program. Please check one of the following:

PDPs Graduate credit

6. Teaching Interest

Please describe your teaching activities and why you want to participate in the program:

7. School Data

Please fill in the following data regarding the student population in your school

- percentage of female students
%
- percentage of underrepresented minority students
%
- ethnicity of the largest underrepresented minority student group in your school

8. Accommodation

Accommodation in WPI residence halls is provided free of charge for participants.

Hotel accommodations are available near campus. (You are responsible for making your own reservations.)

I wish to stay in the WPI residence halls
I will make my own reservations at the Courtyard Marriott hotel
Neither

9. Special Needs

If you are a disabled participant or if you have special needs, please let us know by filling in the following box.

For any questions, please contact:

Tel: 1-508-831-5241
Fax: 1-508-831-5824
Email: cims@wpi.edu

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Last modified: Jun 20, 2010, 09:03 EDT
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