Thirteenth Annual Environmental Health Sciences Summer Institute for Educators
Application Form

Seating is limited; Register early.
Deadline: June 16

You may attend more than one workshop if seats are available. Please select the following workshops in order of importance (from most preferable to least preferable) and check the box of the workshop(s) you would like to attend. Seating preference will be given to applicants who teach within the grade level noted for each workshop.

Please note: If you are applying to the ToxRAP™ or the MedMyst sessions, you must submit a $25 registration fee for your application to be considered final. This registration fee will be refunded in full upon completion of your entire workshop; refunds for cancellations will only be awarded up to two weeks prior to the workshop.

Teachers who attend and complete an entire ToxRAP™ or the MedMyst session, will receive a monetary award.

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First Name
Last Name
Gender
Race

I am requesting a seat in the ToxRAP™ or MedMyst workshops. I understand that I must mail in a refundable registration fee in the amount of $25 to UMDNJ-School of Public Health/CSCHE, to make my registration final. The check will be mailed to UMDNJ-SPH/CSCHE, Liberty Plaza, 335 George Street, Suite 2200, PO Box 2688, New Brunswick, NJ 08903-2688.


: I have read the above and agree.

 

School Address
School Name
District
Address

City
State
Zip
Phone Number
Fax Number
E-Mail
County
        
Home Address
Address

City
State
Zip
Phone Number
E-Mail

Background Information

How many years have you taught?
What subjects?
What grade(s) do you teach now?
How many students do you teach?
Do you teach a bilingual class?
What extracurriculur environmental activities/clubs are you presently involved with or have been in the past?
Do you have any special requirements (i.e., handicapped accessible parking)? If so, please specify.
Every effort is made to provide delicious and nutritious meals. Please let us know if you...

Keep Kosher
Are a Vegetarian

School Demographics

Type of School
Location of School
Estimated minority population of school: %

Recruitment Information

Have you attended previous Summer Institutes or in-service trainings offered by the Resource Center? If so, please select all that apply:


1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
 

 

How did you learn about the Summer Institute?
Principal
Colleague
Brochure to Home
Science Supervisor
Brochure to School
Convention/Exhibit/Seminar
Internet
Magazine/Newsletter (please specify)
Other (please specify)

 

 


 

 

The UMDNJ-School of Public Health is sponsored by the University of Medicine and Dentistry of New Jersey in cooperation with Rutgers, The State University of New Jersey and New Jersey Institute of Technology and in collaboration with the Public Health Research Institute.

For more information contact:
732-235-9095
csche-sph@umdnj.edu