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.
?
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