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How to complete this form:
You can type directly into this form. Click on the “click her to enter text” and also click on boxes to enter “x”.
If you have any questions, please email sibillej@fultonschools.org
Name: Click here to enter text.
If Organization, name of Contact: Click here to enter text.
Email Address
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Website (optional)
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Other website promotional links (optional)
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Primary Contact Phone: ☐
Home
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Cell ☐ Business
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Address
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Secondary Contact Phone:
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Home
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Cell ☐ Business
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City
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State
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Zip
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County
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Science
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Math
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English Language Arts
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Social Studies/History
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Dance
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Technology
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Music
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Storytelling
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Physical Education
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Theatre
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Visual Arts
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Other: Click here to enter text.
What types of programming do you offer? Check all that apply:
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Assembly Performance/Presentation
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Hands-on Workshop
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Multi-day Residency
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Other: Click here to enter text.
Briefly describe, in general, the type(s) of program(s) you offer - 125 words maximum (this box will expand as you type)
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What core content/curriculum area(s) do your programs support? Check all that apply. Later in the application you will be asked to provide specific connects to standards.
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Science
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Math
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Writing
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Social Studies/History
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Poetry/Spoken Word
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Literacy
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Music
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Visual Arts
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Physical Education
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Theatre
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Technology
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Other: Click here to enter text.
- Describe your (or the organization’s) background and expertise in the primary
content/discipline area (125 words maximum -- this box will expand as you type)
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Application Agreement
By completing and submitting this application, I certify that all information contained within my application to this roster is accurate and truthful. I understand that acceptance to the roster is neither a contract for nor a guarantee of employment; that the roster is of limited duration; and that FCS Teaching Museum can eliminate an artist from the roster at any time.
Please enter your “typed signature” and the date below to acknowledge the application agreement:
Signature: _ Click here to enter text.
_____________ Date: ___ Click here to enter a date.
1

(If applying as an organization, please indicate the organization’s history with these populations.)
Please check one of the columns for each item:
GRADE LEVELS
Pre-K
Grades K-2
Grades 3-5
Category
No Experience
/ Not
Applicable
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Beginning to
Moderate Level
of Expertise
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Significant
Experience, generally at least
5+ years
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Grades 6-8
Grades 9-12
SETTINGS
School – during regular school hours
Cultural and Community Organization
Programs (courses offered by a library, museum, theatre, etc.)
Extra-Curricular classes – community centers, after-school clubs, summer camps, private lessons, etc.
PROFESSIONAL DEVELOPMENT (optional)
Leading classes for Teaching Artists
Leading classes for K-12 Teachers
POPULATIONS (optional)
At-risk
Special Needs / Physical/Mental Disabilities
English Language Learners
Other Click here to enter text.
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Extensive
Experience, generally at least
10+ years
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REFERENCES
Name
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Email Address
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Phone Number: ☐ Home ☐ Cell ☐ Work
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Position (i.e. 5 th grade teacher; principal; education
director) Click here to enter text.
School or Organization
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Briefly, note the context from which this reference knows your work.
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Name
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Email Address
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Position (i.e. 5 th grade teacher; principal; education
Phone Number:
director) Click here to enter text.
Briefly, note the context from which this reference knows your work.
Click here to enter text.
☐ Home
Click here to enter text.
School or Organization
Click here to enter text.
☐ Cell ☐ Work
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Learning Program Provider APPLICATION FORM  2016 2

PROPOSED PROGRAMS
Provide a detailed description(s) of one to three programs (i.e. performances, workshops, residencies, presentations, etc.) which exemplify programs you are proposing for FCS students via the Teaching Museum.
The provider if qualified and approved, may be contracted to provide this and/or additional programs.
Proposed Program 1 (Required)
Name of program
Click here to enter text.
How long is the program? (i.e 45 minutes; 60 minute performance & 15 minute Q&A; 20 minute demonstration
& 20 minute hands-on activity)
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What is the program format?
☐ Assembly Performance/Presentation
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Hands-on Workshop ☐ Single-day Residency ☐ Multi-day Residency
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Other: Click here to enter text.
What will students be able to know, understand and/or do after taking part in your program?
Click here to enter text.
The Teaching Museum offers programs which directly supports specific grade-level standards. Which grade level does this program serve?
☐ Pre-K ☐ 1 st ☐ 2 nd ☐ 3 rd ☐ 4 th ☐ 5 th ☐ 6 th ☐ 7 th ☐ 8 th ☐ 9 th ☐ 10 th ☐ 11 th ☐ 12 th
What are the specific grade-level standards met by your program (reference the CCGPS & GPS):
(A strong connection to one standard is necessary and more than one is optional)
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What is the availability of this program? (dates, times, in schools or at museum)
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What is the price per performance/workshop/residency? Include any discounts when booked multiple days, multiple sessions, etc.
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Are there any special booking or reservations requirements or needs? ☐ yes ☐ no
If so, what? Click here to enter text.
Describe space request or set up needs for programs/performance/workshops/residencies.
Click here to enter text.
Describe any additional materials fees or charges
Click here to enter text.
Describe any additional curricular support material, (i.e. pre- or post-program study guides or extension
lessons), provided with your program. Please provide a sample in your application.
Click here to enter text.
Learning Program Provider APPLICATION FORM  2016 3

Proposed Program 2 (Optional)
Name of program
Click here to enter text.
How long is the program? (i.e 45 minutes; 60 minute performance & 15 minute Q&A; 20 minute demonstration
& 20 minute hands-on activity)
Click here to enter text.
What is the program format?
☐ Assembly Performance/Presentation
☐
Hands-on Workshop ☐ Single-day Residency ☐ Multi-day Residency
☐
Other: Click here to enter text.
What will students be able to know, understand and/or do after taking part in your program?
Click here to enter text.
The Teaching Museum offers programs which directly supports specific grade-level standards. Which grade level does this program serve?
☐ Pre-K ☐ 1 st ☐ 2 nd ☐ 3 rd ☐ 4 th ☐ 5 th ☐ 6 th ☐ 7 th ☐ 8 th ☐ 9 th ☐ 10 th ☐ 11 th ☐ 12 th
What are the specific grade-level standards met by your program (reference the CCGPS & GPS):
(One standard is necessary and more than one is optional)
Click here to enter text.
What is the availability of this program? (dates, times, in schools or at museum)
Click here to enter text.
What is the price per performance/workshop/residency? Include any discounts when booked multiple days, multiple sessions, etc.
Click here to enter text.
Are there any special booking or reservations requirements or needs? ☐ yes ☐ no
If so, what? Click here to enter text.
Describe space request or set up needs for programs/performance/workshops/residencies.
Click here to enter text.
Describe any additional materials fees or charges
Click here to enter text.
Describe any additional curricular support material, (i.e. pre- or post-program study guides or extension
lessons), provided with your program. Please provide a sample in your application.
Click here to enter text.
Learning Program Provider APPLICATION FORM  2016 4

Proposed Program 3 (Optional)
Name of program
Click here to enter text.
How long is the program? (i.e 45 minutes; 60 minute performance & 15 minute Q&A; 20 minute demonstration
& 20 minute hands-on activity)
Click here to enter text.
What is the program format?
☐ Assembly Performance/Presentation
☐
Hands-on Workshop ☐ Single-day Residency ☐ Multi-day Residency
☐
Other: Click here to enter text.
What will students be able to know, understand and/or do after taking part in your program?
Click here to enter text.
The Teaching Museum offers programs which directly supports specific grade-level standards. Which grade level does this program serve?
☐ Pre-K ☐ 1 st ☐ 2 nd ☐ 3 rd ☐ 4 th ☐ 5 th ☐ 6 th ☐ 7 th ☐ 8 th ☐ 9 th ☐ 10 th ☐ 11 th ☐ 12 th
What are the specific grade-level standards met by your program (reference the CCGPS & GPS):
(One standard is necessary and more than one is optional)
Click here to enter text.
What is the availability of this program? (dates, times, in schools or at museum)
Click here to enter text.
What is the price per performance/workshop/residency? Include any discounts when booked multiple days, multiple sessions, etc.
Click here to enter text.
Are there any special booking or reservations requirements or needs? ☐ yes ☐ no
If so, what? Click here to enter text.
Describe space request or set up needs for programs/performance/workshops/residencies.
Click here to enter text.
Describe any additional materials fees or charges
Click here to enter text.
Describe any additional curricular support material, (i.e. pre- or post-program study guides or extension
lessons), provided with your program. Please provide a sample in your application.
Click here to enter text.
Learning Program Provider APPLICATION FORM  2016 5

Complete this form and email it and other documents to museum@fultonschools.org
no later than 4 pm on
March 31, 2016.
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Completed Application Form
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Additional curriculum-related support material/study guides/etc. (optional) Include an addendum describing connection or relevance to the program proposal(s) submitted.
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Brochure, flyers, reviews or other promotional materials (optional) Include an addendum describing connection or relevance to the program proposal(s) submitted.
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Web addresses or links to online video, audio, photographs, review, etc. that demonstrations the quality of your programming (optional) Include an addendum describing connection or relevance to the program proposal(s) submitted.
Please note, all applicants accepted and approved as TM Learning Program Providers will be required to submit a copy of their driver’s license, Immigration and Security Forms, and additional forms as required by the FCS
Contracting Department. Additionally, they must complete a brief online abuse training and background check as mandated by FCBOE policy.
Email submissions to museum@fultonschools.org
Any questions? Please email Jena Sibille at sibillej@fultonschools.org
Learning Program Provider APPLICATION FORM  2016 6