Document 6536872

11/14/13
Kenan Institute for Engineering Technology & Science Application System
Please Note: This is a sample application for viewing purposes only. The "Submit Application", "Save for Later" and
"Logout" buttons do not do anything. To apply to this program please visit the application "New User Registration"
page and register with the application system.
Kenan Fellows Program
Application Due Date: Monday, February 10, 2014
Submit Application
Save for Later
Logout
Session Timer: 58:44 minutes
Please save your work as you go as your session will time out after 60 minutes of inactivity.
When you have completed the application, go to the bottom of the application and click "Submit Application".
1) Personal Information
First Name (Legal):
Middle Name:
Last Name:
Preferred Name:
Salutation:
email: john.doe@nonexistantbox.com
alternate email:
Home Address:
City:
State:
Zip:
Home Phone: (
)
-
Cell Phone: (
)
-
2) School Information
School:
Subject:
Please select all that apply.
Grade:
K
1st
7th
2nd
8th
9th
3rd
10th
4th
11th
5th
6th
12th
School Address:
City:
State:
Zip:
School District:
Please select district and school if applicable to view all projects available to teachers in your school.
If other, please specify
Phone: (
)
-
Fax: (
)
-
3) Educational Information
Educational History: List all colleges or universities you have attended. Begin with the most recent.
College/University
Location
Major
Degree
Start Date
End Date
Current
Current
Current
Current
Current
Current
Current
4) Project Information
You may apply for up to three fellowships available in your school district. Your first selection will be considered your top choice.
Fellowship #1 Title:
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Kenan Institute for Engineering Technology & Science Application System
Fellowship #2 Title:
(Optional)
Fellowship #3 Title:
(Optional)
Design Your Own Project: Design Your Own Project: If you select the Design Your Own project, please provide a brief description of the project you would like to complete. In 500
words or less, describe why you are interested in this particular project and how it will benefit students. Save the document as a PDF file and upload it here.
(PDF format only)
Essay: The Kenan Fellows Program seeks teachers to be a part of a network of accomplished educators who model innovation and relevant science, technology,
engineering and math (STEM) connected instruction. Kenan Fellows work to build leadership and instructional skills and develop new lessons based on
unique summer research externships. Please respond to the following four questions.
a.
b.
c.
d.
Why are you interested in a Kenan fellowship?
How do you imagine that this opportunity help you be a more effective teacher?
How do you expect students to benefit from your Kenan fellowship experience?
How do you expect other teachers to benefit from your Kenan fellowship experience?
You may choose to submit your response in 1 of 2 ways. Please select one option.
1. Write a brief essay of no more than 500 words that addresses the 4 questions listed above. Save the document as a PDF file and upload it to the
application. If you do not have a PDF conversion tool, you can use this free on-line PDF converter Neevia Technology. To ensure that your files may
be properly included in your application, please ensure that they are not protected via encryption, a password, a signed certificate or in any other
manner.
2. Create a 3-5 minute video that addresses the 4 questions listed above. Please provide the URL for your video in the text box below. We strongly
encourage you to double check the link prior to submission to ensure it's functionality.
File Upload: (PDF format only)
or Video URL:
(Format: http://www.youtube.com/user/KenanFellows)
5) Teaching Experience
a) Areas of Certification:
b) National Board of Certification Status:
c) Years of teaching experience:
Employment History: List your employment experience. Begin with your current position.
Position/Title
Employer
Location
Start Date
End Date
Current
Current
Current
6) Other Information
List all presentations made at local, statewide and national conferences or workshops. Include the titles of presentations, and the names and dates of
conferences. Enter most recent first:
Title of
Name of Conference
Date of
Audience
Presentation/Publication
or Workshop/Article
Presentation/Publication
List all grants that you have received, include dates and the amount: Enter most recent first:
Name of Grant
Amount of Award ($)
Date Awarded
Technology Use (In 100 words or less, describe 2 technology tools you use most frequently and with the greatest impact. Describe how you use them in
your school.)
(100 words or less)
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Provide specific examples of your role as a teacher leader and describe the impact on other teachers. Enter most recent first:
Name of Role or Activity
Realm of Influence
Start Date
End Date
Current
Current
Current
Current
Current
How did you hear about the Kenan Fellowship?
If other, please describe:
7) Letters of Recommendation Two letters of recommendation are required in support of your application. One must be from your principal and the other should be from an individual
familiar with your work as an educator. List names, titles, emails and phone numbers of two persons from whom you would like to request letters of
recommendation. Once you have submitted your application, we will email them instructions for submitting an online letter of recommendation on your
behalf. Please inform your designees that they will receive an email with instructions from notices@epsso.net. In addition, we may contact them by phone
for additional information. These letters are due by Monday, February 17, 2014.
Name
Position
Email Address
Phone Number
Principal
8) Optional Information
Gender:
This information is for reporting purposes only. It will in no way be considered during the evaluation process.
Male
Female
Ethnicity:
I understand, if I am selected, the Kenan Fellows Program requires a commitment of me including participation in seven weeks of a summer externship
and professional development and completion of a curriculum product to be disseminated to other educators.
Disclaimer: The Kenan Fellows Program is funded through gifts, contracts and grants. Consequently, Kenan Fellowships are contingent upon the continued availability of
such funding. In the rare event that existing funding is terminated or continued funding is unavailable, Kenan Fellowships may be subject to early termination.
If you have any questions about the application process you may reach the Kenan Fellows Program staff at (919) 515-5118 or email us at kenanfellows@ncsu.edu.
Please save your work as you go as your session will time out after 60 minutes of inactivity.
Session Timer: 58:44 minutes
Submit Application
Save for Later
Logout
Application Due Date: Monday, February 10, 2014
Please Note: This is a sample application for viewing purposes only. The "Submit Application", "Save for Later" and
"Logout" buttons do not do anything. To apply to this program please visit the application "New User Registration"
page and register with the application system.
Address: Campus Box 7006. Raleigh, NC 27695
Telephone: 919.515.5118 Fax: 919.515.5831
E-Mail: KenanFellows@NCSU.edu
This system is hosted and maintained by
Education Programs Support Services, LLC.
Facilitating efficiency, scalability and security in educational programs
© 2013 Education Programs Support Services, LLC
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