APPLICATION AND REGISTRATION FORM

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* 1. Name (First and Last):

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* 2. District:

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* 3. School:

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* 4. Principal:

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* 5. What subjects do you teach or have presently taught?

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* 6. Are you teaching out of the field via an emergency or alternative certification?

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* 7. If you are a Special Education Instructor, do you teach Social Studies?

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* 8. If you are an ELA teacher in what ways are history or civics education incorporated into the courses you teach?

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* 9. Discuss ways that you collaborate across the content areas of Social Studies, History, Civics and ELA.

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* 10. Do you belong to any American History Professional Organization or Language Arts Professional Organization?

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* 11. If "yes" which organization(s)?

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* 12. What grades do you presently teach? (check all that apply)

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* 13. Please describe the last time you attended American History and/or Social Studies Professional Development:

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* 14. How many years have you taught or collaborated with American History and/or Social Studies?

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* 15. Are you willing to do the following  (Along with PD up to a $1600 will be provided.)

  Yes No Maybe
Participate in 40 hours in a History Academy?
Participate in one of the following with Students: KYA, KUNA, or National History Capstone Project? 
Participate in 18 hours outside of the regular school year in professional development?
Develop three history lessons?
Possibly travel on a experiential history field trip out of state?
Possibly participate with students in a Congressional Academy?

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* 16. Your school email:

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* 17. Home email:

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* 18. Work phone:

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* 19. Cell phone: 

Contact: Kay Hedrick
Project Coordinator
Kentucky Educational Development Corporation
118 James Court, Suite 60, Lexington, KY 40505
(859) 255-6411

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