Supplemental Application Form: LEDE

Please complete the following Supplemental Application form as part of your overall application to the Leadership Development for Educators program. The complete list of Application Materials is available on the Application Information page. Applications will not be reviewed until all application materials have been received.

Please note: All data entered in this form will be sent directly to the Leadership Development for Educators program upon submission of form.

Applicant Information First Name: Required

Middle Initial:

Last Name: Required

Application quarter:: Required

Spring2011
Autumn2011

Current School: Required

Current District: Required

Teaching Experience Number of Years of Teaching Experience: Required

Indicate all levels taught: Required

Elementary
Middle Level
Secondary

Please list all subjects taught (at middle and secondary level):

Please list any specialist teaching experience or endorsements:

Teaching Leadership Experience Number of years with part- or full-time release in a leadership position involving assisting other teachers with instruction (e.g., instructional coach, mentor):

Document prior work directly related to teacher instructional leadership (up to 200 documented hours may qualify for up to 2 waiver credits):

Describe any additional responsibilities you've had for assisting other teachers with instruction:

List all non-credit professional develoment directly related to teacher instructional leadership (include source and number of hours). Prior professional development may qualify for up to 4 waiver credits.:

Number of years with part- or full-time release in a leadership position not directly related to instruction (e.g. dean of students):

Please specify your leadership role not directly related to instruction:

Number of years of leadership experience outside education (where you had responsibility for supervising others):

Please specify your leadership role outside education:

Please indicate if you have any graduate level coursework* that may qualify toward Leadership for Curriculum and Teaching course requirements:

Please indicate if you have any graduate level coursework* that may qualify toward Personal Leadership for Schools course requirements:

*A student working toward the master’s degree may petition the Dean of the Graduate School for permission to transfer the equivalent of a maximum 6 credits of graduate level coursework taken while a registered graduate student in another recognized graduate school. These credits may not have been used to satisfy requirements for another degree.

Opportunity for Teacher Instructional Leadership Please describe how your current position will support these activities: Required

Please provide the name, telephone number, and email address of a school district supervisor who can confirm the opportunity for completing a part 1 internship in your current position:

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