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| Applicant's
Name : |
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| Email Address
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| Home Address
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| City : |
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| State : |
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| Zip : |
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| Home Phone
(include area code) : |
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| What grade level do you teach : |
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| What subject do you teach : |
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| Principal's name : |
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| School Name : |
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| School Address : |
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| City : |
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| State : |
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| Zip : |
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| School Phone (include
area code) : |
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| School Fax (include area
code) : |
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| Superintendent's Name : |
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| School District : |
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| School District Address : |
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| School
District City : |
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| School
District State : |
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| School
District Zip : |
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Adaptor Program Information
Hint: There is no spell check available within
this application. You might copy and
paste some of your fields into a Word document to check for
spelling and grammar errors.
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1. Title of Disseminator Grant Program : |
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2.
Disseminator's Name :
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3.
Applicant's Contact with Disseminator Teacher: (type of contact -
i.e., telephone, school visit, letter, etc.) :
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4. Please
describe the major comments and/or issues discussed with the
Disseminator Teacher :
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5. When do
you plan to adapt this program in your class :
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6. What is
the educational need for this program in your class/school :
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7. What are
some of the qualities that most impressed or interested you, and
why :
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8. How will
this program be incorporated in your regular curriculum and
classroom program? (please explain goals and objectives in detail)
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9. What materials would
you need in order to adapt this program in your class? (please
list item descriptions and approximate costs for each item needed
- budget cannot exceed $200) :
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10. Do you have the
curriculum packet for the program you would like to adapt :
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Yes
No |
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Program Description
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1. Total number of years teaching experience :
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2. Total number of
students that will be involved in the adapter program. (indicate
the number of students in each grade level. Base your answer on
your current enrollment) :
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3. Indicate achievement
levels and special groupings. (above average, average, below
average, gifted & talented, special education, bilingual,
drop-out prevention) :
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Staff and Resources
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1. What other staff
members would be involved in the adaptation of the program :
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2. If NCE provided funds
for substitute teachers, would you be interested in visiting the
disseminator's school? :
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Yes
No |
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If no, please explain :
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