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Fall Early Literacy Summit: Supporting the Socio-Emotional Development of Young Children
GENERAL INFORMATION
Please fill out all the fields below.
Name
*
First Name
*
Last Name
*
Preferred Phone
*
Email
*
Address (best shipping address)
*
Address Line 1
Address Line 2
City
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Texas
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Virginia
Washington
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Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
YOUR CURRENT EMPLOYMENT INFORMATION
School Name
*
School District (if applicable)
Type of School
*
Public
Private
Charter
Head Start
Childcare Center
Other:
Other Value
School Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
School Phone
*
Administrator Name
*
Administrator Email
*
Grade/Age you will be teaching in the fall
*
Current Classroom Makeup (Choose all that apply.)
*
Regular
Inclusion
Bilingual
ESL
Dual Language
YOUR TEACHING BACKGROUND
How many years of teaching experience do you have?
*
What ages/grade levels have you taught? Please include the dates for each.
*
When considering your current classroom setup, please select all that apply.
*
Large group instruction
Small group instruction
Dramatic play/pretend center
Blocks center
Library/book center
Writing center
ABC center
Math/science manipulatives
Art center
Does your classroom have any of the following? Please select all that apply.
*
Multicultural baby dolls for the pretend center
Emergency vehicles for the block center
Sand or water table
Light table
None of the above
YOUR EDUCATION BACKGROUND
High School/City
*
Year Graduated
*
Certification(s)/degree(s) obtained and granting institutions as applicable
*
ADDITIONAL INFORMATION
In what language does the majority of your instruction take place?
*
If you have a teaching partner, is he/she also applying?
*
What inspired you to apply to this conference?
*
How would your students benefit from you attending this conference?
*
How did Hurricane Harvey impact you, your campus and your classroom?
*
Is there anything else you'd like for us to know?
How did you hear about this program?
*
Signature
Signature
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