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)?YesNoDescribe 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 limit as in may Please 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
