Application for Conceptual Chemistry for Teachers of Grades 4 - 9 Ohio Board of Regents Improving Teacher Quality Program 5 Credit Hour Graduate Course at Kent State University-Stark/Tuscarawas Postmark Deadline: April 18, 2011 Class Meeting Dates: June 13-17, August 13, September 24, October 15, November 4 & 5, and December 3, 2011 Please type or print: Name (official): ______________________________ Soc. Sec. #: ________________ Name (preferred on name tag): _____________________ Birth Date: _____________ Home address: ______________________________City _______________________ County: _________________________________State: _____ Zip: ____________ Primary Phone: __________________ Secondary Phone: ____________________ e-mail: _______________________ School name: ___________________________________Phone: _________________ Street address: ______________________________ City ____________________ County: ___________________________________ State: OH Zip: ___________ Administrator name and title: ___________________________________________ School District (LEA): _________________________________________________ Participant Data: The following information is needed to complete state and federal reports on our project. It will be aggregated for the entire class; individual data will be kept strictly confidential. Please provide the following information about yourself: Gender: Male_______ Female_______ Ethnicity: White, non-Hispanic____ Black, non-Hispanic____ Hispanic____ Asian/Pacific Islander____ American Indian/Alaskan Native____ Other____ (specify): ________________________________________ Education: Year of bachelorÕs degree_______ Institution ________________________ Year of masterÕs degree________ Institution ________________________ Teaching experience, year(s):_____ Number of college chemistry courses completed:_____; Years HS chemistry: ________ Grade level you are currently teaching or preparing to teach: Primary (K-3)____ Intermediate (4-5)____ Middle (6-8)____ High (9-12)____ (If High School, indicate grade level or levels__________) Select the response that best describes the main subject area that you are currently teaching or preparing to teach (select one): Self-contained class (teach most academic subjects)____ Math only____ Science only____ Math and Science____ Other or multi-subject combinations____ (specify): _____________________________ Professional Certification: Elementary____ Early Childhood____ Middle Childhood____ Secondary____ Special Education____ Other_______ (specify): __________________________________________________ Student Data: Please provide information about the students you currently teach. 1. Population of Community where your school is located (check one): Less than 10,000____ Between 10,000 -50,000____ 50,000+____ 2. # Students in my class(es):____ 2. Total # students in my school:____ 3. Approximate # of students in your school who are eligible for free or reduced price lunches:__________________ 4. Approximate # of students in your school who are: a) White, non-Hispanic________ d) Asian/Pacific Islander___________ b) Black, non-Hispanic________ e) Am. Indian/Alaskan Native_______ c) Hispanic________ f) Other, not listed above __________ 5. Approximate # of students in your school who are from: g) Urban (from community population > 50,000)___________ h) Suburban (community with population > 10,000 and < 50,000)_________ i) Rural (from community with population < 10,000)__________ 6. # Students from the following groups: (Students may belong to more than one.) Limited English proficient________ Disabled/Handicapped________ Migrants________ Economically disadvantaged________ Appalachian_______ Gifted and Talented________ Professional Development: Please list experiences (if any) during the last 5 yrs. such as science courses, workshops, conferences, school or district curriculum planning, text selection, any other science education-related activity or leadership experiences. (Use back of page, if necessary.) Personal Statement of Interest: I want to learn more about basic chemistry topics and activities for teaching them because: (Please answer in 50 Ð 150 words below or on the back of this page or on a separate typed page.) Teacher Declaration IF ACCEPTED* I agree to attend all of the class sessions to be held at Kent State University at Stark from 8:00 AM to 4:00 PM on the following 2011 dates: June 13, 14, 15, 16, 17 (M-F) August 13 (Saturday) September 24 (Saturday) October 15 (Saturday) November 4 & 5 (Friday & Saturday) December 3 (Saturday) I understand that class attendance is important for successful completion of the program and confirm that none of the above dates are in conflict with personal or professional events that would result in anticipated absence. I understand that this project includes a 5-semester hour graduate course with tuition and texts paid by an OBR Improving Teacher Quality state grant. The program does not cover application fees to the Graduate College of Kent State University. There will be assignments and tests required for successful completion of the program, a responsibility that I accept. IF ACCEPTED, I understand that I will have to be admitted to the Graduate College of Education, Health and Human Services (EHHS) at Kent State University prior to registration for this class. I will carefully and expeditiously follow the instructions for admission to EHHS when contacted by KSU about admission policies and procedures. I will respond promptly to all inquiries from KSU in order to keep my place in this class. Signed _____________________________________________Date ___________ APPLICANT *Submission of this application does not guarantee acceptance. We have a limited number of openings and admission is selective. Successful applicants must complete registration requirements by June 1, 2011 in order to keep their reservations for this class. Acknowledgement of Administrator If the teacher named here: ________________________________________________ is accepted for the Ohio Board of RegentsÕ Improving Teacher Quality State Grant science project, I will send Conceptual Chemistry the sum of $175 by June 13, 2011, as payment for this teacherÕs in-service budget for classroom science materials. I understand that my teacher, if accepted for this project, will receive more than $800 worth of grant-funded lab materials and activity sets for use in our school. Please make checks payable to: Conceptual Chemistry c/o Mr. Walter Gritzan Kent State University at Tuscarawas 330 University Drive NE New Philadelphia, OH 44663-9403 Additionally, I agree to provide one professional release day, Friday, November 4, 2011, for the above teacher to prepare for student-involving activities related to this project. Signed _______________________________________________Date ____________ ADMINISTRATOR AdministratorÕs name/title (typed or printed) ___________________________________ Billing Address__________________________________________________________ ________________________________________________ Zip __________ Office telephone: _____________________________________ Fax: _____________ Mail or bring completed application to: Conceptual Chemistry, c/o Dr. Christopher J. Fenk Science and Advanced Technology Center Kent State University at Tuscarawas 330 University Dr. NE New Philadelphia, OH 44663-9403 Or FAX application to: Dr. Fenk, Conceptual Chemistry, (330) 308-7552 For more information, call or e-mail: Dr. Christopher J. Fenk Dr. Claudia Khourey-Bowers Phone: (330) 308-7467 Phone: (330) 244-3422 e-mail: cfenk@kent.edu e-mail: cmkhoure@kent.edu