County Funded School-based TIS Assurance Statement and Agreement
If I am selected to participate in the County Funded, School based Technology Integration Specialists Cohort for 2016-17, I hereby
give my assurances that I will:
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Participate in and successfully complete the required professional development under the direction of a WVDE Coordinator
(includes both online and face-to-face sessions) between June 2016 and September 30, 2017;
Use acquired technology integration skills to improve instruction for both students and educators at a school level;
Use enhanced knowledge and skills to build effective consultative and co-teaching relationships with all teachers;
Utilize collaborative planning time to assist in integrating technology into instructional units;
Act as a resource to educators on technology integration, as appropriate, in the implementation of information literacy,
independent learning and social responsibility;
Communicate the importance of developing 21st Century skills for all students to improve their academic achievement and
post-secondary outcomes.
Typed or Printed name of county funded school based TIS candidate
Signature of county funded TIS candidate
Name of School
@k12 Email
Date
School Phone
County
Principal Assurance Statement and Agreement
I hereby give my assurances that I will support the above requirements for the County Funded School-based Technology Integration
Specialist initiative. I agree to accommodate the necessary release time and schedule to accomplish the assurances.
Typed or printed name of Principal
Signature of Principal
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Principal’s @k12 Email address
Date
County Technology Contact Assurance Statement and Agreement
Equipment required for TIS Candidate participation
 New Laptop (minimum OS of Windows 8 or latest iOS OS)
 Data projector
Equipment access at the TIS candidate’s assigned school to:
 Electronic Whiteboard
 Scanner (may be part of a combination unit)
 Color printer (may be part of a combination unit)
I hereby give my assurance that I support the requirements for the County Funded School-based Technology
Integration Specialist initiative. I agree to accommodate the necessary equipment purchase by mid-June.
Typed or Printed Name of County Technology Contact
Signature of County Technology Contact
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Phone Number
Email address
Date
Superintendent Assurance Statement and Agreement
For the purposes of implementing the provisions of the County Funded School-based Technology Integration Specialist initiative:
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The County agrees to support implementation of the Technology Integration Specialist model to ensure successful
implementation at the assigned school site.
The County understands and supports the participant’s requirements as follows:
o Participate in and successfully complete the required professional development under the direction of a WVDE
Coordinator;
o Be allotted the opportunity to use acquired technology integration skills to improve instruction for both students
and educators at the school level;
o Use enhanced knowledge and skills to build effective consultative and co-teaching relationships with all teachers;
o Utilize collaborative planning time to assist in integrating technology into instructional units;
o Act as a resource to educators on technology integration, as appropriate, in the implementation of information
literacy, independent learning and social responsibility;
o Communicate the importance of developing 21st Century skills for all students to improve their academic
achievement and post-secondary outcomes;
o If awarded one of the $3000 grants, any expenses exceeding this amount is the responsibility of the county.
o If the TIS does not complete the program the county will be asked to return the remaining balance of the grant.
The required professional development includes that following:
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Online introductory collaborative sessions during May – July, 2016
Attendance at face-to-face sessions at Tamarack in Beckley (June 14, 15 & 16, 2016)
Attendance at face-to-face conference at the Waterfront Place in Morgantown (July 18 - 22, 2016)
Participation in online courses
Participation in face-to-face workshops throughout the school year; and
Other professional development opportunities related to topics such as project based learning, specific technology tools,
online content resources and instructional technology integration.
The County agrees to make available the following:
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Funds for travel, stipends and other expenses for selected TIS candidate to attend professional development during the
summer of 2016
Funds for necessary travel and release time for selected TIS candidate to attend all professional development during the
2016-17 school year
Provision of funds to provide the required technology equipment
Assurance that the County Technology Contact supports this professional development by participating in the acquisition of
required hardware by the mid-June, 2016 deadline
Typed name of County Superintendent
Signature
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@k12 Email address
Date
Return all signed documents to:
WVDE
Office of Technology Integration and Support
ATTN: Lori Whitt
1900 Kanawha Blvd., East
Charleston, WV 25305
Or fax to:
ATTN: Lori Whitt
304-558-2584
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