Workshop Teacher Registration Form for Database

Registration Form for
Modeling Middle School Science
June 17-28, 2019, 7:30 AM-2:00 PM, Fee: $325

15 of 28 Places Filled.

Registration FormConfirmationOnline Payment

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 *
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
Registration Information Confirmed:*
Leave blank:
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