Application

2003-2004 Cryptography Field Test Teachers

 
1. First Name Last Name Grade

2. Setting     Classroom    Afterschool    Museum    Other

3. Home Address:
    Street
    City   State Zip
    Home Phone e-mail address
4. Name of school or other setting
    Street
    City   State Zip
    School Phone Fax
 
Description of School/Program
5. Coed            All boys      All girls
6. Suburban      Urban   
7. Public           Private
8. Please describe your students:
        
9. Are computers available to your students? Yes      No
    If so, how many per classroom?     Is the internet available to your students? Yes      No

10. How do you expect to teach the module?
    at one time      distributed throughout the year      other
    When during the year do you expect to teach the class?

11. Number of years teaching experience
12. Please write a description of why you would like to pilot this material: