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2020-CREI-Application Civil Rights

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NPS Form 10-973 (Rev. 11/2016)
National Park Service
OMB Control No. 1024-2018
Expiration Date 09/30/2019
APPLICATION FOR 2020 CIVIL RIGHTS EDUCATOR INSTITUTE
JULY 13 – 17, 2020
LITTLE ROCK CENTRAL HIGH SCHOOL NATIONAL HISTORIC SITE
2120 W. Daisy L. Gatson Bates Drive
Little Rock, Arkansas 72202
Phone: (501) 374-1957
Fax: (501) 396-3001
Email: [email protected]
Website: https://www.nps.gov/chsc
The 2020 Little Rock Central High School National Historic Site Civil Rights Educator Institute (CREI) is a design laboratory for social
engagement that provides a space for self-reflection and inquiry into issues related to human rights and education for liberation. This
institute brings together educators, community workers, and cultural activists to exchange knowledge and experiences + learn with and
from each other in an intensive week-long learning community.
The Institute offers experiential approaches and narrative strategies as tools to explore civil rights history and human rights struggles.
Using place-based learning, we will visit civil rights sites in the City of Little Rock and critically engage with issues of rights, struggle,
story, and power of place and introduce innovative ways of connecting past to present.
The CREI is a place to build community and solidarity + share multiple views and explore the work of educators as connected to civil
and human rights. Participants will create a knowledge camp and initiate concentric conversation to diminish social and cultural barriers
where they receive facilitation tools for classroom social action. Participants will receive credit for this professional development
coursework.
GENERAL INFORMATION
Last Name
First Name
Mailing Address
City
Cell Phone
Middle Initial
State
Suffix
Zip Code
Email Address
SCHOOL OR ORGANIZATION INFORMATION
Name of School/Organization
Supervisor’s Name
Mailing Address
City
Phone Number
State
Zip Code
Type of School/Organization
Age/Grade Level of Students/Participants
Public
Private
Community Organization
PARTICIPATION FEE
There is a $100 participation fee which supports costs of field trips, course materials for the workshop, coffee/tea, lunches and
snacks. Evening meals are at participant’s own expense.
If application is accepted, I can pay the $100 fee by June 1, 2020
(The National Park Service is unable to cover expenses such as airfare or visa fees, but will provide lodging for all
participants who do not live in commuting distance.)
LODGING
Lodging is recommended if commute would be more than a 1 hour drive to Little Rock. Lodging will provided at no expense to
participants based on double occupancy. Participants who do not wish to share a room will need to pay an additional per night fee
for a private room. Participants who choose to stay at other local hotels, bed & breakfasts, etc. would do so at their own expense. A
list of hotels near the meeting site can be provided upon request.
I do not need lodging provided or will arrange lodging at my own expense.
Yes, I request NPS provided lodging and willing to share a room with two queen beds.
My preferred roommate is:
I have no roommate preference.
Gender for roommate assignment:
Male
Female
I will pay the per night additional fee for a private room – fee will be determined at a later date with sponsoring hotel.
RECORDS RETENTION. TEMPORARY. Destroy/Delete 3 years after closure. (NPS Records Schedule, Interpretation and Education,
(Item 6C) (N1-79-08-5))
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NPS Form 10-973 (Rev. 11/2016)
National Park Service
OMB Control No. 1024-2018
Expiration Date: 09/30/2019
LODGING (Continued)
Do you have any accessibility needs you want to share:
Do you have any dietary restrictions or allergies:
No
No
Yes (If “Yes”, please explain:)
Yes (If “Yes”, please explain:)
MISCELLANEOUS
Please explain how you learned about the Civil Rights Educator Institute? Was it recommended to you for a particular reason? If so,
by whom?
ONE-PAGE ESSAY
Please write a one page essay that addresses the following questions and return with your completed application. The essay should
address the following:
1. A brief description of the project you wish to develop at the Institute and/or your interests.
2. What do you hope to take home from the Institute?
3. What would you like to share/exchange with other participants?
4. What is your role in your organization/school/institution?
5. How will your participation in the Civil Rights Educator Institute potentially impact your work and/or organization?
How to Submit Application:
Submit completed application, your resume and the one-page essay by email, fax, or mail to:
Email:
[email protected] (Please put “CREI 2020” in the subject line)
Fax:
(501) 396-3001 Attn: Brian Schwieger
Mail:
National Park Service
2120 W. Daisy L. Gatson Bates Drive
2020 CREI Application
Attn: Brian Schwieger
Little Rock, AR 72202
Our review of applications will continue until all seats are filled.
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NPS Form 10-973 (Rev. 11/2016)
National Park Service
OMB Control No. 1024-2018
Expiration Date: 09/30/2019
NOTICES
Privacy Act Statement
General: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 21, 1984, for individuals
completing this form.
Authority: The authority to collect information on the attached form is derived from one or more of the following:
The authority to collect information on the attached form is derived from one or more of the following:
Collection and use is covered by Privacy Act System of Records OPM/GOVT-1 and USDA/OP-1, and is consistent with the provisions
of 5 USC 552a (Privacy Act of 1974), which authorizes acceptance of the information requested on this form .
Purposes and Uses: To process applications for the 2020 Civil Rights Educator Institute, to make selections to fill the limited number
of seats in this professional development workshop, and to ensure that information needed to make sure participant health and safety
requests are met, including any special needs
Effects of Nondisclosure: Failure to disclose may impact the ability to meet special needs in compliance with the Americans with
Disabilities Act and to assess the appropriateness of this workshop for an applicants desired goals.
Paperwork Reduction Act Statement
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to provide the park managers the
information needed to decide whether or not to allow the requested use. All applicable parts of the form must be completed in order for
your application to be considered. You are not required to respond to this or any other Federal agency-sponsored information collection
unless it displays a currently valid OMB control number. OMB has approved this collection of information and assigned OMB Control
No. 1024-2018
Estimated Burden Statement
Public reporting burden for this form is estimated to average 30 minutes per response including the time it takes to read, gather and
maintain data, review instructions and complete the form. Direct comments regarding this burden estimate, or any aspects of this form,
to the Information Collection Clearance Officer, National Park Service, 12201 Sunrise Valley Drive, Mail Stop 242, Reston, VA 20192.
Please do not send your completed form to this address.
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