Application Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastWhat is your title?How many years of experience do you have in education?Email *Phone Number *Home Addres *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWhat is your current school district? *What school do you represent? *Years at current employer? *What grade(s) do you represent (as applicable)? *What course/area is your primary focus? *Does your school identify as a Title 1 school (if applicable)?YesNo employer? is Signature Describe your current job responsibilities. *Why would you like to participate in the Educator Industry Academy Program?250 word limitWhat expectations do you have for the EIA program?250 word limitPlease list any dietary and/or environmental restrictions you may have.Participant AcknowledgementsRequirements Statement *I agree to the statement below.I recognize my commitment to the Educator Industry Academy (EIA). If selected to participate, I will make every effort to complete all requirements and graduate with my cohort. I acknowledge that attendance is mandatory to receive recertification credits, that I will engage and participate in sessions, and that I will complete and present an Action Plan. If an absence is required, I will notify Elisabeth Kovacs within 72 hours of a session and will participate in a make-up session to be eligible for graduation. Employer Statement *I agree to the statement below.My employer is aware of the standards and expectations of this program, and if I am selected, fully supports my involvement. I represent myself and my employer and will conduct myself in a professional manner that reflects favorably upon each. Permission Statement *I agree to the statement below.I hereby grant permission to EIA to use photographs and/or video of me taken throughout the course of the EIA program in publications, news releases, online, and in other communications related to the program and its work.Your Signature * Clear Signature Submit
