Fellow Application

Note: Questions in bold are required.

General Information

First Name:
Last Name:
Primary Email:
Confirm Primary Email:
Secondary Email:
Gender:

Home

Home Address:
Home Address 2:
Home City:
Home State:
Home Zip:
Home Phone:	- -

School

(For the purpose of your response to the following, High School is defined as 9-12 grades and middle school as 6-8 grades.)
Position:
HS Biology HS Integrated Science MS Physical Science HS Chemisty HS Environmental MS Earth Science HS Physics HS Astronomy MS Integrated Science HS Physical Science MS Life Science/Biology MS Environmetal Science HS Earth Science MS Chemisty MS Astronomy HS Forensics Other HS: Other MS:

School:
School Locale:
School Type:	Other:
Site Administrator:
School District:
School Address 1:
School Address 2:
School City:
School State:
School Zip:
School Phone:	- -
School Fax:	- -

Education Background

(Teaching is defined as being the teacher of record and does not include student teaching or long-term substitute teaching)

Number of years teaching at the end of the 07-08 school year:

Number of years teaching science at the end of the 07-08 school year:

Grade Level Teaching in 08-09:

6th9th11th
7th10th12th
8th

Priority grade level for mentor match :

Courses Teaching in 08-09:

1:
2:
3:
4:
5:

First priority subject area for mentor match:

HS Biology HS Integrated Science MS Physical Science
HS Chemisty HS Environmental MS Earth Science
HS Physics HS Astronomy MS Integrated Science
HS Physical Science MS Life Science/Biology MS Environmetal Science
HS Earth Science MS Chemisty MS Astronomy
HS Forensics Other HS:
Other MS:

Second priority subject area for mentor match:

List your undergraduate degree(s):

Your degree area(s):

Areas of science related study if not part of your major:

What type of teaching credential do you hold:

What are your area(s) of endorsement?:

Have you previously or are you currently, participating in graduate work?

Yes
No

If so please describe degree(s) or program:

School Context: Provide information about your school or teaching context that could assist us in matching you with a mentor. This could include information such as special teaching assignments, school demographics or class demographic information.

The e-Mentoring program, developed by NSTA, the New Teacher Center, and Montana State University will provide you with a content matched mentor and access to an online community of science educators. What do you anticipate will be the greatest benefit of participation in the e-Mentoring aspect of the Academy? What are potential challenges to participation?

Most school systems provide professional development and/or mentoring support for their teachers or provide access to professional development offered by other agencies. Briefly describe your access to science professional development and/or mentoring support.

Briefly describe the anticipated impact of your participation as an NSTA Fellow on your professional development and teaching.

The NSTA Fellowship provides the opportunity for you to attend the NSTA National Conference and become more involved in the science education community. Describe any opportunities you have had as a new teacher or student teacher to become involved with your profession outside of your classroom. A few examples of involvement are: student NSTA chapter membership, membership in any professional organizations, attending professional conferences, participating in any school or district science committees or teams, or involvement with a community based science project. Please provide a brief explanation as to your role in each.

Please let us know where you have easy internet access:

At School:	Yes No
At School High Speed:	Yes No
At Home:	Yes No
At Home High Speed:	Yes No

Participation

I have read the New Teacher Center E-Mentoring Overview for 2008-09 and if accepted as an NSTA Fellow, I agree to accept and meet these expectations.
In order to be eligible to participate as an Academy Fellow, you must print and return both signature documents. Both must be signed and returned by May 30, 2008. One is for your administrator and the other for you. I have printed both signature documents.

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