Scientist in the Classroom Program
This is a sample registration form for the scientist.

Scientist Registration Form

I am willing to volunteer to share my interest in science, engineering, medicine and mathematics with Triangle area teachers and students. I understand that filling out this form does not obligate me to any commitments, but only indicates my willingness to consider requests for assistance that would be made by Partnership staff.

Name:____________________________________________________

Position/Company:___________________________________________

Indicate preferred correspondence location:

Work Address:______________________________________________

Home Address:______________________________________________

Company Phone:______________________________________

Home Phone:______________________________________

Fax:________________________

E-mail Address:_______________________________________

My specialty area in science/math/engineering:_________________________________

OTHER interests potentially related to science/math/engineering I could share with students and teachers: __________________________________________________________

We wish to provide positive role models and encouragement for groups underrepresented in science, math and engineering. If you would be willing to specifically assist us in this regard, please let us know if you are a member of such a group (eg. African American, Native American, female, etc.)_________________________

I could meet with school children and their teachers_______times per____________
(1,2,3 or more) (month, semester, or year)

I prefer to volunteer at the following times or on the following days:__________________

I am willing to visit schools in the following school districts in the greater Research Triangle area: (Please check preferences)

o All five school districts o Granville County o Chapel Hill/Carrboro

o Chatham County o Durham County o Wake County

If you have school age children, what school(s) do they attend?____________________

Have you visited elementary, middle, or secondary school students and teachers before:________________

Although I understand my name and other information on this form will not be released without my permission, I do / do not (circle one) wish my name to be shared with other volunteers who want to discuss a particular activity.

(You may want to provide the scientist with the list of activity topics from the Elementary activity manual, often used by teachers in making requests. Please take a minute to circle the titles you think you would like to try.)