R&D Spring 2015 Pilot Application

General Information & Demographics

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* 1. Please complete the information below:

Name: *

School/Organization: *

Address:

Address 2:

City/Town:

State:

ZIP:

Email Address: *

Phone Number: *

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* 2. Which of the following best describes your position? (Check all that apply)

Teacher

Administrator

Superintendent

Curriculum Specialist

Program Coordinator

Parent

Volunteer

Other (please specify)

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* 3. Which of the following applies to the students being served through your school/organization? (Check all that apply.)

Early Childhood/Primary Center

Elementary (K-2)

Elementary (3-5)

Middle School (6-8)

High School (9-12)

Out-of-School Time/Afterschool*

Other*

*Please specify age group(s) served:

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* 4. What is the percentage of students based on gender?

Female

Male

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* 5. What is the percentage of students based on ethnicity?

African American/Black

American Indian/Alaskan Native

Asian/Pacific Islander

Hispanic

White/Caucasian

Other

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* 6. What is the percentage of students on free/reduced lunch?

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* 7. Check all that apply for the following priority categories: (*able to provide supporting documentation upon request)

Low SES School*

Race to the Top "Turnaround School"*

Rural and/or Rural Low Income School*

Urban School

Current ASSET Member

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* 8. Is your school/organization willing to participate in a focus group to reflect upon your experience in a pilot?

Yes

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* 9. Is your school/organization willing to provide evidence of student and/or teacher outcomes in the form of interviews, surveys, student work samples, video, photography, and/or site observations?

Yes

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* 1. Please complete the information below:

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* 2. Which of the following best describes your position? (Check all that apply)

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* 3. Which of the following applies to the students being served through your school/organization? (Check all that apply.)

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* 4. What is the percentage of students based on gender?

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* 5. What is the percentage of students based on ethnicity?

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* 6. What is the percentage of students on free/reduced lunch?

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* 7. Check all that apply for the following priority categories: (*able to provide supporting documentation upon request)

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* 8. Is your school/organization willing to participate in a focus group to reflect upon your experience in a pilot?

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* 9. Is your school/organization willing to provide evidence of student and/or teacher outcomes in the form of interviews, surveys, student work samples, video, photography, and/or site observations?

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* 10. Why is your school/organization interested in participating in an ASSET STEM Education pilot?