Participant Data Form

Thank you for providing information for our data report to ALAHASP funding agencies..

First Name*(*)
Please type your first name.

Last Name*(*)
Please enter your last name.

E-mail*(*)
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Preferred Phone Number
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Home Address
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City
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State
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Zip Code
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System*(*)
Please enter your school system.

School*(*)
Please enter your school name.

Grade Level(s)*(*)
Please enter your grade level(s).

TOTAL number of students in all your classes*(*)
Please enter the total number of students in all your classes.

TOTAL Number of science students in all your classes*(*)
Please enter the total number of science students in all your classes.

Are you currently teaching out of field?*(*)
Please tell us if you are currently teaching out of field.

Certificate level in the field in which you are currently teaching:*(*)
Please specify the certificate level in the field in which you are currently teaching.

Certificate Level-Other, Please specify:
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Highest Academic Degree Attained:*(*)
Please indicate the highest academic degree you've obtained.

Other, Please specify:

Highest Degree-Other, Please specify:
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Grade Level(s) you teach/counsel:*(*)
Please enter your grade level(s).

Number of years of full-time professional teaching/administrative experience:*(*)
Please enter the number of years of full-time professional teaching/adminstrative experience.

Current Role:*(*)
Please tell us your current role/position.

Current Role-Other, Please specify:
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Please list the kits you have been trained to teach.
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List the names of the science kits you have used in your classroom:
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Would you like to be notified of ALAHASP professional development opportunities?
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May ALAHASP have your permission to use any photos taken during this event in which you appear to promote future workshops and events?
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*Denotes required field.

First name you would like to be printed on your workshop badge:
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Alternative Contact Information:
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Please enter the following characters:(*)
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