Workshop Teacher Registration Form for Database

Registration Form for
Modeling Physics: Electricity and Magnetism
July 10-21, 2017, 7:30 AM-2:00 PM, Fee: $300

24 of 28 Places Filled.



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Teacher's Information for Workshop

Entries with * are required.

First Name: *
Last Name: *
Home Phone: *
Email Address: *
IEIN (Illinois Educator Identification Number):
Home Address1: *
Home Address2:
Home City: *
Home State: *
Home Zip Code: *

Teacher's School Information

Currently teaching: * If yes, fill in the rest of this section. If no, skip it.

School Name *
Your School Email: *
Your School Phone: *
Address1 *
Address2:
School City: *
School State*
School Zip: *
School District:
 If you do not see your school district in the pull-down, enter it below.

Other School District:

Subjects and Grades
Currently Teaching: *

Confirm Registration Information

Please review all your information and set Registration Information Confirmed to "Yes" to indicate you are ready to submit the registration. Then click Submit Registration
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