Academy Registration FormOn submission of this form, you will receive an endorsement form by email. This is to be signed by your principal and returned to us. Your acceptance on the Science Academy is not confirmed until we receive the signed endorsement form. Places are limited to 24 teachers.

1Name and school

First Name Last Name School Name

Town/City

2Contact details

Email Confirm Email Mobile Phone Emergency Contact Name Emergency Contact Number

3Academy

Prefered course

How did you hear about us?

4Your Teaching Background

Year levels you're currently teaching Previous year levels taught Total years teaching Have you completed any tertiary level science courses in the last three years? Yes No * If yes please provide a brief outline Have you completed any science-specific professional development? Yes No * If yes please provide a brief outline

5Other Info

Do you have any special dietary requirements? Yes No * If yes please provide details Please provide a short (one paragraph) biography that can be used in the Academy programme I agree to the Terms and Conditions Yes *

Terms and Conditions

By attending the Sir Paul Callaghan Science Academy, you are granting permission for the Sir Paul Callaghan Science Academy to photograph and/or film you at the Academy and use it free of any charge, for promotional purposes. You agree to participate in all Academy evaluations, and where practical and by negotiation in any public relations activities, including interviews during, or post the Academy. You also agree to receive occasional emails about the Sir Paul Callaghan Science Academy and other programmes from the National Science-Technology Roadshow Trust.

You may withdraw from the Academy without penalty up to three weeks prior to the first date of the selected course. A no-show or withdrawing within three weeks wil incur a $70 administration fee.

If you have any questions, comments or concerns regarding the Sir Paul Callaghan Science Academy, please contact us at: info@scienceacademy.co.nz