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* Last Name

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* First Name:

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* School District

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* Name of school in which you work (If you are a district-wide or central-office staff, please type in "District Wide" or "Central Office".)

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* School Address

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* Home Address & Information

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* Check one:

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* Grade Levels you teach (Check appropriate grades)

  Pre-K K 1 2 3 4 5 6 7 8 9 10 11 12 Adult Ed. Post-Secondary
Level

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* Number of years teaching:

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* Subjects you teach:

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* Are you teaching on a waiver?

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* Are you teaching out-of-field?

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* Are you teaching without an appropriate license?

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* Are you a teacher of English language learners?

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* Are you a teacher of students with disabilities?

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* Are you applying as part of a team?

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* Why are you applying for this institute?

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* Please briefly describe your current content knowledge and skills relative to this course topic.

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* What do you expect to learn from this course, and how do you expect it to affect your professional practice in the future?

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