Bay Area Circle for Teachers
Workshop Registration Form


Personal Information

First Name (required):
Middle Name:
Last Name (required):
E-Mail (required):
Home Address:
Home Phone Number:
School Name (required):
School Address:
Work Phone Number:
Grade Level:

Equal Opportunity Information

WHY THIS INFORMATION IS BEING REQUESTED:
MSRI receives support from the National Science Foundation (NSF), which is an agency of the Federal Government.

The Federal Government has a continuing commitment to monitor the operation of its grant and award processes to identify and address any inequities based on gender, race or ethnicity.

Submission of the requested information is voluntary and will not affect the applicant's eligibility for any program, however, if you are declining to furnish this information, you must check the appropriate boxes indicating so.

Please be aware that information not submitted will seriously undermine the statistical validity, and therefore the usefulness, of information received from others.

An individual not wishing to submit some or all of the information should check the box provided for this purpose.

Demographic data allows NSF to gauge whether their programs and other opportunities in science and technology are fairly reaching and benefiting everyone regardless of demographic category; to ensure that those in under-represented groups have the same knowledge of and access to programs and other research and educational opportunities, etc. The information on this part is solicited under the authority of the National Science Foundation Act of 1950, as amended. All information provided will be treated as confidential and will be safeguarded in accordance with the provisions of the Privacy Act of 1974.


FOR U.S. CITIZENS AND PERMANENT RESIDENTS ONLY

Gender: (Choose one response)    


Ethnicity: (Choose one response)


Race:
Select all that apply or choose "Decline to State".

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Decline to State



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