Teacher Institute Application

Name
Date of Birth

Tribal Affiliation (if applicable)

Gender MaleFemaleNonbinaryPrefer not to answer

Home Address

,
,
Phone
Personal Email
Work email

If I am selected, I give permission to share my email address with other participants.
YesNo

School Name
Address
,
,
Phone

School website (if applicable)

Grade levels you teach (select all that apply)
Pre-KKindergartenFirstSecondThirdFourthFifthSixthSeventhEighthNinthTenthEleventhTwelfth

Do you teach at a Title I School? YesNo

Subject(s) you currently teach (select all that apply)
Art history/visual artsLibrary scienceScienceEnglish/language artsMathSocial studiesELL/ESL/ESOLMedia/technologySpecial educationForeign languageMusic/performing arts
Other
Total number of years spent teaching

Name
Relationahip
Preferred phone number
Alternate phone number

Biography

Interest in Attending

American Indian Integration

Which of the following influenced your decision to apply to the Heard Museum Teacher Institute (select all that apply?
Integration of American Indian subject-matter into my curriculumDates of sessionCostLocationFinancial support from districtMuseum name
Other

Have you attended any of the following Heard Museum Educator Events in the past?
Please check all that apply.
Teacher InstituteEducator Open HouseBoarding School Teach-In

Are you receiving financial support from your district for attending this workshop?
YesNo

How did you learn about the Heard Museum Teacher Institute?

Please check one:
I have reviewed the program and activities, and I can take part without restrictions or accommodations.I have reviewed the program and activities, and I can take part with the following accommodations. (Please describe below any restrictions you may have with mobility or any other special needs and we will try to make appropriate accommodations.)

The workshop will be limited to 30 participants and will meet for eight hours a day (9 a.m. to 4 p.m.) for a total of three days.

I, agree to complete the Heard Museum Teacher Institute from June 22 to 24, 2020. I will actively engage and cooperate with the staff, artists, guest speakers and peer participants during the program. I am responsible for completing the program requirements, participating in activities, and cooperating with the museum for additional grant-reporting measures. I will not bring any type of weapon(s) or use any alcohol or drugs during the duration of the workshop, except for those prescribed for medical purposes by a doctor.

I understand that I am responsible for arranging my own transportation to Phoenix, Arizona for the program, as well as my return home.

I accept the terms of participation

As a condition of my participation in the Heard Museum Teacher Institute, I hereby give permission to the Heard Museum, 2301 N. Central Avenue, Phoenix, AZ 85004:

1. To interview me, to photograph me (still or moving images), to record my voice,

2. To use, reuse, publish and republish the same in whole or in part for any lawful purposes in any media whether now known or hereafter existing, including print, broadcast and the internet,

3. And to use my full name in connection therewith.

I will make no monetary or other claims, including any and all claims for libel, for the use of the interview and/or the photograph(s)/video/recording of my voice.

This authorization and release also applies to the organization(s)/publication(s) for which the photographer/interviewer took the photos/video, recorded applicant’s voice and/or conducted the interview, and to their legal representatives, licensees, and assignees.

Applicant may note exceptions by itemizing below aspects to which the applicant does not agree. Applicant reserves the right to decline to answer certain questions and to stop the interview if he/she becomes uncomfortable. He/she may refuse the use of his/her full name and/or address and may refuse to have his/her full face photographed.

Publicity/Use exceptions

I agreeI agree with the above exceptions