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Please complete all required fields (marked with a ).
Fields designated as "other" or "optional" may be left blank. Incomplete applications will not be considered.

Teacher Information

Name  Title  Primary e-mail address  Secondary e-mail address  Home Telephone (with area code) School Information (Note: Only high schools are eligible to apply.)  School  Principal's full name  Department chair's full name  Address  City  State  Zip  Telephone (w/area code)  Fax Website (opt) http://  School Setting [Select Setting:] Rural Suburban Urban Is your school?  Public  Private  Home School

Class Information

 Class name

Please enter the name of the participating class(es) below.

 Grade level

 Class duration

One quarter   Two quarters   Semester   Year-long

If this is a one-quarter class, which quarter?
1st   2nd   3rd   4th

If this is a two-quarter class, which quarters?
1st   2nd   3rd   4th

If you are on a Quarter system, please provide the start and end dates for each quarter below. (Ex. November 18)

If you are on a semester system, please provide the start and end dates for each semester below. (Ex. November 19)

 Breaks
Please provide Start and End Month/Dates for spring and winter breaks in the area below. (Only hit "Enter" if you are starting a new line.)

  What percentage of students in this class speak English as a second language?
%

What is the primary language, other than English, spoken by students in your class as their first language?

 Is this an honors or advanced placement class?
Yes   No

 Is this a basic skills or low ability class?
Yes   No

 Is this a required or elective class?
Required   Elective

 What percentage of students enrolled in the class do you estimate will have access to the Internet from home?
%

 Will students in this class be required to take any standardized test during your class period between January-May 2011?
Yes
No

If yes, when?

Teaching Experience

 Number of years teaching

 Have you participated in the Summit in the past?

Yes
No

If yes, when?

 Please explain the student learning objectives that you will seek to meet by participating in the National Online Youth Summit, It’s the Law: Guarding the Nation’s Health.

 Please explain how you plan to integrate the Summit and the topic into your course.

  How did you learn about the National Online Youth Summit?

ABA Division for Public Education website

Colleague / Friend

NCSS Annual Meeting

E-mail notification (Source of e-mail)


Advertisement (Name of Publication)


Other (Please specify)