Name:

  Email:

  Address:   Phone:

  Employer/School (shipping address for materials):

  School Name:     School Phone Number:

  Street:  
  City:      
  State:    

  Current Teaching:

  Mini-Grant Requested for Classroom Materials:

  $50      $75      $100      $200      Other

  What kind of materials do you wish to purchase? (Make sure you include a complete shopping list!)

  Posters/books/CDs      Laboratory equipment      Computer equipment     

Please explain the relevance to the field of nuclear astrophysics, why you want these materials, how you would use them in the classroom, and how this would enhance your curriculum and your teaching.

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  The complete shopping list of all items you requested:

  WHAT you want:
                COST:
  WHERE to order: 

NOTE: We cannot send money, but can buy materials and have them shipped directly to you.

This application form must be completed by each teacher applying to the program, and may not be completed and/or submitted by another individual.

For more information, contact:

Micha Kilburn, Ph. D.  (mkilburn@nd.edu)
JINA Outreach Coordinator
Office Phone: 574-631-5326
180 Nieuwland Science Hall
University of Notre Dame
Notre Dame, IN 46556

Zachary A. Constan, Ph.D.  (constan@nscl.msu.edu)
NSCL Outreach Coordinator
Office Phone: 517-333-6363
National Superconducting Cyclotron Laboratory
Michigan State University
East Lansing, MI 48824