Name:

Home Address: Phone:

City: Zip:

E-mail Address:

Bachelor's Degree:
Institution: Major: Year:

Do you have a teaching certificate?

If your answer is YES, what level and content area? (if you have more than one certificate, list all certificates)
1st certificate: level content area:
2nd certificate: level content area:
3rd certificate: level content area:

Have you taught any of the following (with or without a certificate): Elementary, Middle School, or High School? If so, please list which ones.

Subjects you have taught:

Please list the college mathematics courses you have taken.

Which courses are you interested in taking during fall 2002? Data Analysis and Probability (Columbia area) Geometry (St. Louis)

Are you interested in possibly taking future outreach courses during the academic terms (WS2003, FS2003, WS2004) and/or during the coming summer (SS2003)? If so, please list which semesters.