Academy Membership Application Cover Page – Protégé Category
Name:
Date:
Academic
Department:
Section/Training
Program:
School:
Campus Address:
Campus
Telephone:
Other Telephone:
Month/Year you began your education program:
Month/Year you expect to complete education program:
Current Educational Status:
Resident, PGY- _____
Fellow, Year-____
Post-doctoral Fellow, Year-____
Doctoral, Year-____
Name and Position of Academy Sponsor:
Name and Position of Direct Supervisor:
Check each teaching/education domain that reflects your primary interest and intended focus of professional development within the Academy:
Direct Teaching
Curriculum Development,
Instructional Design & Assessment
of Student Learning
Advising and Mentoring
Leadership and Service
List the one required letter of support as #1 (see guidelines for specifics). Add rows to include any other letters that you have chosen to solicit.
Name / Institution / Dept
Position / Role
Email Address
Educational Research
Telephone Number
1.
2.
Please check the appropriate attestation to indicate your agreement, then sign and date in the appropriate space:
Role
Attestation
Applicant
Supervisor
Academy
Sponsor(s)
Signature
Date
I have personally assembled this application in consultation with my Academy sponsor(s).
If accepted, I agree to fulfill the expectations of a Protégé member in the Academy, as set
forth in Section 1 of the Membership Guide.
I agree to support this applicant’s full participation in the Academy and the associated
mentoring relationship.
If accepted as a Protégé, I agree to fulfill my role as an Academy sponsor/mentor for this
applicant.
Latest Update 3/7/2011