Please be sure to include all
necessary information including SS#.
School: District:
Address:
Telephone: Fax:
Date & location of Regional Institute team will attend: __________________________
1. Team
LEAD (will act as contact for team) SSN:
Address:
Phone number: Email:
Circle One: • Administrator •
Teacher (New to ILAST) • Teacher (Project Based/participated ILAST
2000-2001)
2. Participant SSN:
Address:
Phone number
Email:
Circle One: • Administrator •
Teacher (New to ILAST) • Teacher (Project Based/participated ILAST
2000-2001)
3. Participant
SSN:
Address:
Phone number
Email:
Circle One: • Administrator •
Teacher (New to ILAST) • Teacher (Project Based/participated ILAST
2000-2001)
4. Participant
SSN:
Address:
Phone number
Email:
Circle One: • Administrator •
Teacher (New to ILAST) • Teacher (Project Based/participated ILAST
2000-2001)
Teams consist
of three to four members working collaboratively to support the effective use
of technology for learning and instruction at their school or district.
Total team
members _____________
(3 or 4)
I support the commitment of these
team members to complete 120 hours of training and understand the total team
obligation is $1000.
Signature of Principal or
Administrator
Title
____________________________________ Purchase Order NO. Date
Fax to: ILAST
Partnership
FAX 760-729-8754
Attention:
Email: jhanor@csusm.edu or khayden@csusm.edu