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Contact Us

Jack Hunt STEM Center
Austin Peay State University
PO Box 4545
Clarksville TN 37044
(931) 221-6153
Fax (931) 221-1292
mcilveenem@apsu.edu
bjones12@my.apsu.edu

Home » Stem » Application for Momentum: 2011-2012

Application for Momentum: 2011-2012

Last Name: *

First Name: *

Home Address: *

(Street address) (City) (State) (Zip code)

Home Phone: *

Format: (xxx) xxx-xxxx

Cell Phone:

Format: (xxx) xxx-xxxx

Email:

email

APSU A#:

APSU A#

School Name:

School Name

Name of Principal:

Name of Principal

School Address:

(Street Address) (City) (State) (Zip Code)

School Phone:

Format: (xxx) xxx-xxxx

School Fax Number:

The First to the Top program requires that participation in Momentum be in teams of at least two teachers per school: *

Please list the other teacher(s) on your team.

List Colleges or Universities: College, Degree, Year

Other Information:

Name of Principal:

Certification #:

Expiration Date:

Area of Licensure:

Area of Endorsement:

Subjects and grades currently teaching:

FULL TIME or PART TIME:

FULL TIME

PART TIME

(Please circle one)

Total Years of Teaching:

Currently enrolled in any university?:

YES

NO

Name of University:

Currently enrolled in Graduate courses at APSU?:

YES

NO

If yes, what is your program or concentration?:

Are you interested in starting a program at APSU?:

YES

NO

** If you have attended APSU in recent years, you have been assigned an identification number starting with “A.”

Please describe any STEM professional development you have had:

describe any STEM professional development you have had in the last three years and give the approximate number of hours or days involved.

Does your school already have in place a consent form for video recording?:

YES

NO

Evaluation of all First to the Top STEM projects is being coordinated by the funders. All participants are guaranteed anonymity by the evaluators and confidentiality by the Momentum Project Directors. By applying for participation in this project, you are agreeing to participate in this evaluation. It consists of providing videos of three of your lessons (recorded from the back of the room) over an 18-month period and participating in pre- and post-assessments. We will assist you in accomplishing all of these assessments while remaining anonymous to the evaluators. Does your school already have in place a consent form for video recording? If not, we will provide one for you.

Date:

Austin Peay State University | Addresses | Clarksville, TN 37044 | 1-877-861-APSU | (931) 221-7011
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