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

Is the participant a current member of MnSTA (Minnesota Science Teachers Association)?
 Yes
 No
 Don't Know

Will the PARTICIPANT be compensated for their participation in an ESTEP workshop in the form of a stipend, or 1 graduate credit (includes completion of assignments in addition to attending the workshop)?
 Stipend
 1 credit
 Neither

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