Individual Team Member Application for SEIR*TEC School Leadership in Technology Academy
Orlando, Florida
June 13 16, 2000

This form must be signed and received along with the team application on or before April 10, 2000. Mail or fax to: Vicki Dimock, Southwest Educational Development Laboratory, 211 East Seventh, Austin, TX 78701. Fax: 512/476-2286. Download application in Word format

Name (please print or type)

School District

School Site

Position (e.g. teacher, administrator, parent, school board member, education support personnel, district personnel, student, business/community representative, other)

Year-Round Mailing Address

City/State/Zip Code

Home Phone (including area code) School Phone (including area code)

E-mail address

Special Dietary or Accommodation Needs

I am attending the School Team Academy to work on our identified problem because I can contribute in the following ways:

My signature below indicates my full understanding of the commitment I will be making if our application is accepted. I agree that I will be in complete attendance and will participate fully in the SEIR*TEC School Leadership in Technology Academy, June 13 16, 2000. I further understand that my signature provides my release to use my photo or likeness in any publications or documentation of the School Leadership in Technology Academy. I also understand what constitutes acceptable use of the Internet and World Wide Web resources and will conduct myself accordingly while in attendance at the Academy.

Team Member Name (printed or typed)     Position/Title

Signature                                                    Date

For additional information regarding the SEIR*TEC School Leadership in Technology Academy, please contact Vicki Dimock at 1-800-476-6861, extension 219 or by e-mail at .