ITest

ITEST Summer 2006 Application

*Denotes required fields

Personal Information
First	*
Last	*
Gender	Female Male
Race	*
Ethnicity	*

Contact Information
Street Address	*
	City* State* Zip*
Home Phone	(xxx-xxx-xxxx)*
Cell Phone	(xxx-xxx-xxxx)
Work Phone	(xxx-xxx-xxxx) *
E-mail Address	*

Education Information Please specify majors and areas of study
College Major
Graduate Degree
Other Degree Certification

Enter other careers you have had besides teaching (if any)

School or Organization Information
School District / School Name	*
Organization Name
Street Address
	City State Zip
Phone Number	(xxx-xxx-xxxx)
Principal / Supervisor Name	*

General Information
Have you ever worked with Lego educational products before?	Yes No
If yes, please explain your involvement.
Have you ever taught with Lego Robotics before?	Yes No
If yes, please explain how they were used.
Have you done any programming?	Yes No
If yes, with what programming language and can you explain your involvement.
Briefly explain why you are interested in attending this professional developement program.

Summer 2006 Application

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