1. Name*
2. Telephone*
3. Position*
4. E-mail Address*
5. How would you prefer to be contacted?* (choose one)
   E-mail Telephone
6. If you would like to be contacted by phone, what are the best hours to contact you?

1. School*
2. District*
3. Address*
4. Address (con't)
5. City*
6. County*
7. State*
8. Zipcode*

Please keep in mind that we cannot teach all classes.  Classes will be chosen based on volunteer availability.

	Subject	# of Students	Time	Class Duration
Class #1
Class #2
Class #3
Class #4
Class #5

Would you be interested in having a small group of students meet with a DNA Day ambassador to discuss biomedical careers? 

Yes   No

Below are a list of DNA Day modules for 2010.  The curriculum for the modules are aligned with the NCSCOS for biology except for "The Chemistry of the PCR Reaction" which is aligned with the NCSCOS for chemistry.

*Please choose three that you are most interested in having a DNA Day ambassador present to your students.  We will do our best to accommodate teacher preferences, but your module choice is not guaranteed.

(For a module description, click on the module's name)

1. Pharmacogenomics Module
2. Genes and Diseases Module
3. Cystic Fibrosis Module
4. Farming and Biotech Module
5. Forensics Module
6. Immunology Module

Please include any additional comments you may have: