Participant First Name:
Participant Last Name:
Preferred Email
Participant Phone Number
School/Organization Name
Name of person completing this form
Email of person completing this form
Phone contact for person completing this form
Participant Mailing Street Address
Participant City
Participant State
Participant Zip
Participant Year-Round Phone Number
Participant Email
Participant School District
Participant's School's County
On-campus housing will be available. This would be an additional cost to the participant, and not included in the ESTEP registration fee. Cost ranges from $40-$80 per night depending on the campus. Is the participant interested in on-campus housing? Yes No Not Sure Yet
Will the PARTICIPANT be compensated for their participation in an ESTEP workshop in the form of a stipend, or 3 graduate credits (includes completion of assignments in addition to attending the workshop)? Stipend 3 Credits Neither
Is the participant a current member of MnSTA (Minnesota Science Teachers Association)? Yes No Don't Know
What special needs or accommodations can we be aware of to support the participant?
Additional comments?
Please advise the participant to add estep@mnsta.org to their contacts/address book to be sure that they receive ESTEP correspondence, and that they can respond in a timely manner. **This is important.** I will