Name: _________________________________________ (Maiden / Previous _____________________________________) Home Address: ___________________________________________________________________ ________________________________________________________________________________ Home Phone: (_______)________________ Email Address _______________________________ Date form submitted: ___________________ Social Security Number ______________________ High School: _____________________________________________________________________ High School Address: ______________________________________________________________ ________________________________________________________________________________ High School Phone: (______)____________ High School Fax: (____)_______________________ I have read the Rules & Requirements for teachers and I wish to be considered for an honorarium faculty appointment so that I might participate as a teacher in the University of Colorado at Colorado Springs CU Succeed Program. ________________________________________________________________________________ Signature of Applicant (and date) ________________________________________________________________________________ Signature of High School Principal (and date) Submit this form with your vita and a syllabus of your high school's course (including topics covered and dates) to: CU Succeed Program
Department of Mathematics
University of Colorado at Colorado Springs
1420 Austin Bluffs pkwy
Colorado Springs, CO 80918 For additional information contact the Department of Mathematics at University of Colorado at Colorado Springs, phone: 719.255.3035, or send inquiries to: smichaux@uccs.edu. |