Form A

1. General Information

Please provide an answer for each item, writing NONE wherever it may be appropriate. (Please type.)

........................................................................................................................................................................

Ms. Mr. Mrs. Dr. (circle preferred)

Name:                                                                                                                              SSN:

Home Address:

City: State: Zip:

Home Phone: (      )                                                                Work: (       )

 Fax:                (       )                                                                E-Mail:

District/Institution:

School/Department:

Years of Teaching:                                                                  Grade Level(s) Now Taught:

Current/Pending Subject-Area Assignment:  

Passport Number:                                            Date Issued:                             Date Expires:

.....................................................................................................................................................................

Emergency Information:

In case of an emergency, please notify:

Name:

Address:

City: State: Zip:

Home Phone: (      )                                                                    Work: (      )

E-mail:                                                                                          Fax: (       )

Please indicate your health/accident insurance company:

Company Name: Agent:

Policy Number: Location:

Phone: ( ) Fax: ( ) E-mail:

.....................................................................................................................................................................

2. Educational Background

Bachelors

Institution Major Minor Year

Masters

Institution Major Minor Year

Doctorate

Institution Major Minor Year

Other Grad.

Work Institution Major Minor Year

.......................................................................................................................................................................

3. Professional History (Use additional sheet if necessary.)

Starting with this year, please provide information regarding your educational employment over the past seven years.

Dates Employer Assignment Supervisor
 
 
 
 
 
 
 
 

.......................................................................................................................................................................

4. Professional Publications/Presentations (Use additional sheet if necessary.)
 
 
 
 
 
 
 
 

.......................................................................................................................................................................

5. Professional Memberships/Activities (Use additional sheet if necessary.)
 
 
 
 
 
 
 
 

.......................................................................................................................................................................

6. Special Interests (Use additional sheet if necessary.)

What are your special interests, hobbies, recreational activities, etc.?
 
 
 
 
 
 

.......................................................................................................................................................................

7. Other Information (Use additional sheet if necessary.)

Please feel free to attach other information that you think would be helpful as your application is being considered.
 
 
 
 
 
 
 
 
 
 
 
 
 
 

.......................................................................................................................................................................

COLUMBIA EDUCATION CENTER ECHO PROJECT

.......................................................................................................................................................................

The following form is required from the applicant's immediate supervisor (principal, dean, superintendent, etc.). Use additional sheets if necessary.
 
 

Ms. Mr. Mrs. Dr.

Your Name:

Name of School/Department:

Name of District/Institution:

Address:

City: State: Zip:

Phone: ( ) Fax: ( )

E-mail:

........................................................................................................................................................................

1. Please describe the applicant's present or planned in your agency in regard to environmental education, international/intercultural education, economic education and/or educational technology.
 
 
 
 
 
 
 
 
 
 

........................................................................................................................................................................

2. Please describe the applicant's professional accomplishments, including those areas in which you have observed particular strengths or weaknesses.
 
 
 
 
 
 
 
 
 
 
 
 

........................................................................................................................................................................

3. Please describe the applicant's potential as a "change agent" with colleagues, especially in regard to future efforts in curriculum reform and professional development.
 
 
 
 
 
 
 
 
 
 
 
 

........................................................................................................................................................................
 
 

4. From your own observations, how would your describe the applicant's philosophy of education as evidenced by his or her day-to-day practices?
 
 
 
 
 
 
 
 
 
 
 
 
 
 

.......................................................................................................................................................................

5. Please make any other comments that you feel should be taken into consideration as the applicant's qualifications are being reviewed.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

.......................................................................................................................................................................

All answers will be treated in a completely confidential manner.
 
 

Submitted by:

Typed name and Title Signature
 
 

Date:
 
 

......................................................................................................................................................................
 
 

Please return this form to the appropriate university coordinator or directly to CEC.
 
 

COLUMBIA EDUCATION CENTER ECHO PROJECT

Form C

As part of the arrangement which provides federal funding to help educators take part in this overseas professional development project, a degree of cost-sharing by participant's institutions is expected. Part of the ECHO selection process, therefore, relates to each applicant's assurance that local support has been committed.
 
 

Minimally, the applicant's school or agency must:

Provide any released time days that might be necessary just before the start of the school year. (Project participants may not be returning from abroad until mid-August.)
 
 

Provide facilities and incidental financial support for local ECHO-related in-service presentations and/or workshops that the participant may wish to conduct during the 1999-2000 school year.
 
 

Provide supplementary books, materials, and other instructional items which may be required as the application works to integrate ECHO-related activities in his or her instruction.
 
 

Provide appropriate computer and Internet access for participant's ECHO-related webguide development and implementation.
 
 

Additional forms of cost-sharing--- e.g., tuition reimbursements, project participation fee, domestic travel expenses, etc.--- are also encouraged.

........................................................................................................................................................................
 
 

We agree to the principle of cost-sharing and will contribute to our applicant's participation in the ECHO project as follows:
 
 

1.
 
 

2.
 
 

3.
 
 

4.

........................................................................................................................................................................
 
 

Submitted by:

Typed name and Title Signature
 
 

Date:

........................................................................................................................................................................