* Required Field

* First Name:   

* Last Name:   

Address 1:   

Address 2:   

City:   

State:    (Select State)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutD.C.DelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zipcode:   

Telephone 1:   

Telephone 2:   

* School:   

District:   

* Email:   

* The goal of a Teach Epidemiology Professional Development Workshop is to increase the frequency with which epidemiology is taught by middle and high school teachers. Given our goal and the fact that enrollment in the workshop will be limited to 20 participants, please explain why your application should be accepted.

I agree to:

• Attend all Teach Epidemiology Professional Development Workshop meetings.
• Complete all Teach Epidemiology Professional Development Workshop assignments.
• Teach selected existing epidemiology lessons to other Teach Epidemiology Professional Development Workshop participants.
• Participate in all Teach Epidemiology Professional Development Workshop evaluations.