Institution:

Home mailing address:

School mailing address:

Office phone: home phone:
fax:

Your email address (required):

Gender: male      female

Citizenship (select one):
citizenship U.S. Citizen U.S. Permanent Resident Non-U.S. Citizen

U.S. Permanent Resident country of origin:

Non-U.S. Citizen country of citizenship:

Visa/Immigration status:

U.S. Citizens and Permanent Residents: this question is optional, but helpful in assessing efforts to attract a diverse group of participants (select one):
Ethnicity (Optional) African American Asian American Caucasian Native American Hispanic

How did you hear about PCMI? (select one) 
how you heard about PCMI Advisor Faculty member Colleague Poster/literature Internet Advertisement

If advertisement, please specify publication:

Will you be able to attend the entire PCMI program? (July 11-July 31, 2004) Yes  No
If not, please specify dates you can attend:
(Attending the entire session is encouraged for all participants.  High school teachers who receive financial support from PCMI are expected to attend the entire three-week session.)

SECTION 1: Education and Teaching Experience (Please use as much space as necessary to complete this section)

A. Educational Background (Please supply name of institution(s), degree(s) earned, major(s) and dates)

B. Other Relevant Professional Development (Please supply name of activity(ies), sponsoring agency(ies), and dates)

C. Teaching Experience (Please supply name of institution(s), subjects taught and dates)

Section 2: Professional Development and Outreach Group information

Please choose one:

1. I am an alumnus/alumna of a previous PCMI Summer Session.
   Year(s):
   Name of (site) group:
   
2. I am already an active member of a PCMI Professional Development and Outreach group but have never attended a Summer Session.

   Name of group:

3. I am applying at-large to the summer session.

If you have attended PCMI before, please skip to section 3B.  All other applicants should complete section 3A.

3A) Applicant's Statement

Please write a concise statement describing:

1. your interest in participating in the IAS/Park City Mathematics Institute with respect to what you would like to learn and the changes you would like to make in your own classroom teaching,
2. your aspirations and leadership potential for furthering high school mathematics education reform efforts among the other teachers in your geographic area,
3. your commitment to continued learning of mathematics.

3B) Returning Applicant's Statement

Please write a concise statement describing:

1. Your activities related to the work at PCMI with respect to your own classroom.
2. Activities in which you engaged outside of your classroom that supported the work from PCMI.
3. Your reason for seeking to continue your participation in the IAS/Park City Mathematics Institute.

 Section 4: Letter of Support and Recommendation (not required for teachers who are already involved in a PCMI Professional Development and Outreach group)

1. Please submit two letters of support; one from an administrator, and one from someone else indicating your qualifications for participation in the high school mathematics teacher program.  If you are active in a PDO group, one of your letters must be from the PDO group leader.  Please specify the names and titles of your references below:

1.

High School Principal    Mathematics Supervisor   

Chair, Mathematics Department     PDO Group Leader

Colleague    Other 

2.

High School Principal    Mathematics Supervisor   

Chair, Mathematics Department     PDO Group Leader

Colleague    Other 

Letter(s) should be sent to:

IAS/Park City Mathematics Institute
c/o Dept of Mathematics
University of Utah
155 S. 1400 E., JWB 233
Salt Lake City UT 84112

Or via email to pcmi@ias.edu

Section 5: Working Group Participation

As part of their summer activities, each participant selected for the 2004 High School Teacher Summer Program will be assigned to a small subject-specific working group, which will prepare a first draft of an activity (with the associated mathematics) for piloting during the following year (see web site for more detail). Working groups will be formed around a flexible set of topics that depends to some extent on participant interests.  Please indicate your assignment preference below by numbering your preferences 1, 2, and 3. You are required to make three choices.

Accepted participants will be notified of their group assignment prior to the Summer Session.  If you are a returning applicant from the Summer of 2004, please indicate the group in which you are already involved.

Choice 1:  Combinatorics Data Analysis, statistics and probability Geometry Japanese Lesson Study Functions (required)

Why did you select this group (1)?

Choice 2:   Combinatorics Data Analysis, statistics and probability Geometry Japanese Lesson Study Functions (required)

Why did you select this group (2)?

Choice 3:   Combinatorics Data Analysis, statistics and probability Geometry Japanese Lesson Study Functions (required)

Why did you select this group (3)?

Note that these topics may change before the Summer Session. All participants will be notified of any changes.