Scienteer Registration Form

Welcome to iPRAXIS. With the help of Scienteers like you, we aim to improve science education for under-represented students, increase the participation of minorities in the business of science and technology, and guarantee that scientific breakthroughs benefit everyone.

Please take a few moments to complete this registration form. We will use the information to design the best possible scienteering experience for you, the students, and the teachers at our partner schools. Thank you, in advance, for scienteering. Together, we can ensure innovation for all.

Contact Information

Salutation:

First Name:

Last Name:

Preferred Name:
(optional)

Email Address 1:

Email Address 2:
(optional)

Work Phone:

Cell Phone:
(optional)

Street Address:

City:

State:

Zip:

Background Information

Race/Ethnicity:
(check all that apply)

African-American/Black

Arab/Middle Eastern/North

Asian/South Asian

White

Pacific Islander

African

Native American/Indigenous


  

Other/More Details:

Latino/Hispanic

 

Date of Birth:

Gender:

Educational Experience

Undergraduate:

Degree:

Major/Focus:

Month/Year Completed:

Graduate:

Degree:

Major/Focus:

Month/Year Completed:

Relevant Experience

Organization/ Company:

Title:

Area of Expertise:

Year(s):

Organization/ Company:

Title:

Area of Expertise:

Year(s):

Organization/ Company:

Title:

Area of Expertise:

Year(s):

Related Experience

(including any volunteer work with children, adolescents, and teachers):

Organization/ Company:

Role:

Year(s):

Organization/ Company:

Role:

Year(s):

Hobbies/ Interests:

Your Scienteering Interest

In what ways would you like to scienteer?
(check all that apply)

Guest Teacher

Career Talk

Science Fair
Advisor

Science Fair Judge

Mock Task Force
Moderator

Field Trip
Chaperone

Curriculum
Developer

Behind-the-Scenes Strategist

Program Advocate

Teacher Training
 

Other (specify):

 

From the options you chose above, which is your FIRST choice?

In what subject areas are you interested in scienteering?
(check all that apply)

Biology

Chemistry

Physics

Forensic Science

Technology (e.g., nanotech, biotech, IT)

Science career awareness

Aviation

  

Other (specify):

How often would you like to scienteer?

When would you like to scienteer? (check all that apply)

Weekday morning
(8 a.m. – noon)

Weekday afternoons
(noon – 5 p.m.)

Weekday evenings
(5 p.m. – 9 p.m.)

Saturdays

Sundays

  

Other (specify):

On which days/dates are you absolutely NOT available?

iPRAXIS Program Development

How did you hear about iPRAXIS or scienteering?
(check all that apply)

Word of mouth (e.g., colleague, friend)

Internet search/iPRAXIS website

Advertisement/poster

Newspaper article

Radio announcement

School-related publication

Company notice

Professional association

 

Other (specify):

Do we have your permission to do the following (in support of our Scienteer Directory):

Photograph you

Publish your contact information

Publish your current place
of employment or
educational institution

All of the options

None of the these