Teacher Application | Maryville University

Personal Data

Name

FirstLast

Sex*

Female
Male

Are you a U.S. citizen?*

Yes
No

Ethnicity*

School Name*

Address of School*

Street AddressAddress Line 2CityStateZIP Code

School Phone*

Email*

Home Address*

Street AddressAddress Line 2CityStateZIP Code

Home Phone*

Cell Phone*

Do you have any personal or physical conditions that should be considered for food service, room assignment, or other situations?*

Yes
No

If so, please explain*

Due to the symposium being held during Lent, will you need a fish dinner on Friday?*

Yes
No

Vegetarian meals both nights?*

Yes
No

Roommate*

Smoking
Non-smoking

Name of Local Newspaper*

Address of Local Newspaper*

Street AddressAddress Line 2CityStateZIP Code

Program

Condition for Attendance*

University funded
Self-funded (Cost: $145) Please make your check payable to “Maryville University.” Mail your payment to: Maryville University, Attn. Sue Arnott, College of Arts & Sciences, 650 Maryville University Dr. St. Louis, MO 63141
Observer (Attending open or non-cost activities only)

Will you need a room for a bus driver?*

Yes
No

If yes, the bus driver is*

Female
Male

Does the bus company require that the driver have a private room (for an additional charge)?*

Yes
No

Does the bus driver wish to have meals with the participants?*

Yes
No

Do you need an invoice sent to your school for request of payment? *

Yes
No

If yes, amount*

Would you be willing to serve in an administrative capacity for the JSEHS?

For example, would you consider being a:

Moderator for the sharing paper session?*

Yes
No

Judge for debate trials to select two debate teams?*

Yes
No

Group leader for a field trip on Friday morning?*

Yes
No

Chaperone for the Friday night Ice Cream Social at the hotel? *

Yes
No

Supervise the pool area at hotel?*

Yes
No

Acknowledgement of Participation

Acknowledgement of Participation*

As teacher or sponsor, acting in loco parentis, I plan to attend the Missouri Regional Junior Science, Engineering and Humanities Symposium at the University of Missouri-St. Louis, March 8-9, 2013 and supervise and chaperone the students entrusted to me by my school/district.

Field Trips

Please rank 1-8 in order of your preference (1 being first choice). We are allowing only teachers to request a field trip site. Students will receive a random field trip ticket that they can trade with another student. We will try to accommodate as many teachers as possible but you may not receive your first or second choice.

Alberici Headquarters*