Leadership Teacher: Application

Application Form for LTI: Real World Workshops...

Personal Information Please complete all required contact fields [] below. IMPORTANT*: If you are already a member of Leadership Teacher and have an account on this system, please log in using the 'Member Login' form (-->) before continuing.
* First Name:
* Last Name:
Nickname:
School / Company:
* Email Address:	(Note:* Your email address will serve as your 'User ID'. Please use an email account that is accessible year-round)*
* Password:
* Password (Confirm):
	Interested in eMentoring
	Interested in signing up for Grad Credits

Program Information Enter any relevent Program information below:
Program you are applying for:	(View school district list)
Contact Information
* Home Address:
Home Address (Cont.):
* City:
* State:
* Zipcode:
* Phone #:
Cell #:
Employment
School District (if applicable):
* Current School/Employer:
School/Employer Website:
* Address:
* City:
* State:
* Zip:
* Phone #:
* Grade Level:
* Subject(s):
* Total # of Years Teaching:
Other Subjects Taught
Subject:
How many years:

Subject:
How many years:
Education Please list education, training, and/or specialized programs.
School:
Major/Degree:
Dates:

School:
Major/Degree:
Dates:
Application Questions Please limit your response to no more than one (1) paragraph per question:
What special ways have you contributed to the school in which you teach?

How would you like Leadership Teacher to help you in that effort?

Please share some thoughts on how you might disseminate outcomes from participating in this program with your school or school district.
Tuition School District Cost: $700 for 1 teacher; $600/teacher for 2 teachers; $500/teacher for 3 or more teachers.
Principal/Assistant Superintendent/Superintendent Confirmation This application requires confirmation from either your school's Principal or your school's Assistant Superintendent or Superintendent. Please provide their email addresses below so that we can send them a copy of this application for their approval.
* Principal's Name:
* Principal's Email Address:

* Asstistant Superintendent's Name:
* Assistant Superintendent's Email Address:

* Superintendent's Name:
* Superintendent's Email Address:

*In order to prevent SPAM or automated mailers, please type the two words you see in the box below to verify yourself.