SPIRAL TEAM MEMBER LIST FORM

SPIRAL TEAM MEMBER LIST FORM

To be considered for a SPIRAL award, complete this form and return to: Roberta Eddy, Chemistry Department, 143 Weyandt Hall, IUP, Indiana, PA 15705 by November 1, 1999. The 5-member team must consist of:

an administrator (can be a principal, assistant principal, curriculum director, or head of department)
a special needs or learning support instructor
three K-12 teachers (specifically an elementary teacher, a middle school teacher, and a high school teacher) of mathematics and science (biology, chemistry, geoscience, physics, etc.)

School District:

Administrator’s Name: Phone:

Mailing Address: E-mail:

Soc. Sec. #:
Name of School: _____________________________________

Special Needs Instructor’s Name: Phone:

Mailing Address: E-mail:

Soc. Sec. #:
___Elementary ___Middle ___High School; Name of School:______________________________________

Elementary Teacher’s Name: Phone:

Mailing Address: E-mail:

Soc. Sec. #:
Specialty: ; Name of School:_______________________________________

Middle School Teacher’s Name: Phone:

Mailing Address: E-mail:

Soc. Sec. #:
Specialty or discipline: ; Name of School:_______________________________________

High School Teacher’s Name: Phone:

Mailing Address: E-mail:

Soc. Sec. #:
Specialty or discipline: ; Name of School:_______________________________________