KENT STATE UNIVERSITY

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1 KENT STATE UNIVERSITY Regents STARTALK Teacher Leadership Academy: Chinese, Russian Director: Brian J. Baer / Co-director: Theresa A. Minick Program Dates: Thursday, July 7 - Saturday, July 16 Summer 2016 Application for Admission Deadline: April 15 (Applications will be reviewed on an ongoing basis until all spots are filled.) completed application to Please TYPE: Section 1 Legal Last Name: Legal First Name Middle Name Suffix (Sr., Jr., II, III, etc.) Previous Last Name Gender: Male Female Birth date: Month Day Year Have you previously applied to any campus of Kent State University? Yes No If yes, list the campus, year, and term of previous application and KSU Student ID # Section 2 Permanent Address and Phone Permanent Street Address. City: State: Zip: County: Home Phone ( ) Cell Phone ( ) Address Section 3 Personal Information Are you a United States citizen? Yes No If no, and you are a permanent resident, provide your country of citizenship, permanent resident card number and date granted. Are you an Ohio resident? Yes No 1

2 Ethnic Category Ethnic information is used for reporting purposes only. Please select one or more as appropriate: African American (Black) American Indian or Alaskan Native Hispanic or Latino Caucasian American (White) Asian American or Pacific Islander American Non-U.S. Citizen Next of Kin: Relationship (Example-spouse): Name Last Name First Name Middle Permanent Street Address City State Zip County Home Phone ( ) Cell Phone ( ) Address Have you ever been convicted of a criminal offense or have charges pending against you at this time (other than minor traffic violations)? Yes No Have you ever been dismissed, suspended or placed on probation by any other college or university for a non-academic reason? Yes No Section 4 Teaching Information Do you have licensure? Yes No Name of University granting licensure Year Name of School where you teach School District School Address Number and Street Phone Number County City State Zip Language (s) you teach: Levels of Language: Elementary Middle School High School Years of Experience: 2

3 Section 5 Educational Background Previous College Information Complete previous college attendance. (Include degree programs as well as individual courses) Institution City/State From - To Month and Year : Kent State University Kent, Ohio 9/2010-5/2012 Degree Obtained (if any) OR, if it was just a course, type in the name of the course M.A. Education Section 6 Professional Development List professional development experiences with STARTALK programs Name of STARTALK Program Location City/State Date Brief Description Kent State Teacher Leadership Academy Kent, OH Summer 2014 Best Practices & Technology. List professional development experiences during the last 3 years (workshops / conferences) Workshop / Conference / STARTALK program Location City/State Date(s) Brief Description OFLA IPA Workshop Columbus, OH March 2014 Integrated Performance Assess. 3

4 Section 7 Narrative Please type a paragraph explaining why you would like to participate in the Teacher Leadership Academy. (What are your strengths in teaching? What challenges do you have at your school? What areas/skills would you like to improve? Etc. (Be as specific as possible and include as much space as needed) Section 6 Applicant Signature By my signature I attest to the fact that all information given on this application is complete and correct. Any intentional omission or falsification will result in denial of admission or immediate dismissal. Applicant s Signature Date Director: Brian James Baer / Co-director: Theresa A. Minick Applications to the address below: OR mail to: STARTALK Teacher Leadership Academy ATTN: Theresa Minick 109 Satterfield Hall Kent State University Kent, OH

5 Office Use Only Accepted Denied Name of program if grant supported: Date Admitted in Banner: Processor: TLA Staff Signature: Date: Comments: 5

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