Last Name First Name Have you Attended NCCAT Before Yes No Personal Address City State Zip Code School Name School District/County School Email Personal Email Phone Contact Please use the following format for your phone: XXX-XXX-XXXX Phone Contact Type Cell Phone Home Phone Other Occupation - Select - Teacher Administrator other Ocupation Other Please Indicate your Occupation What grade level are you teaching? What subject do you teach? # of full-time years teaching in NC # of total years teaching Gender Female Male Disclosure of this information is voluntary. It is requested solely for statistical purposes. Ethnic Origin - None - American Indian African American HIspanic Caucasian Asian/Pacific Islands Other Disclosure of this information is voluntary. It is requested solely for statistical purposes. Program Selection 13851 Seize the Data! Cleveland County Feb 2, 2015-May 31, 2015 13797 Seize the Data! Open Enrollment Feb 20-May 22, 2015 Notes/Comments This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit