Content Enhancement Secondary School Institute
    Strategic Instruction Model (SIM)
    July 12-15, 2004
    Please complete all information requested. Project CENTRAL is a grant funded by the Florida Department of Education
    and your complete information is vital in fulfilling the grant requirements and providing you with quality professional
    development and accurate communication of this and future professional development opportunities.
    First Name
    Last Name
    Home Street Address
    Home
    City, State, & Zip
    Social Security Number *
    School/Agency
    Work Street Address
    Work
    City, State & Zip
    Home Phone
    Work Phone
    Email Address
    Work Fax
    Home:
    Work:
    Home County
    Completed Years of
    Teaching Experience
    Job Title:
    Circle one below
    Math Teacher, Science Teacher,
    ESE Teacher, Principal
    *Social Security Number is needed for reimbursement purposes. Accommodations for participants who have special
    needs will be available.
    Accommodations will be based on double occupancy.
    ?
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    Requested Roommate:___________________________________________
    ?
    ‰
     
    I would like a private room and will pay for ½ of the room rate.
    ?
    What would you like to learn at this training that may help you in the classroom?
    ‰
     
    _________________________________________________________________________________________________
    Please return completed registration form by June 30, 2004
    :
    Project CENTRAL
    Attention: Margie Ringler
    1673 Mason Ave. Suite 207
    Daytona Beach, FL 32117
    FAX: (386) 274-0179
    Phone: (386) 274-0175

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