LIPSCOMB UNIVERSITY
GRADUATE STUDIES
Graduate Studies in Education
Ayers Leadership Fellow Scholarship Application
PROGRAM: Choose one:  MEd Educational Leadership  Ed.S. Educational Leadership
Social Security Number: ____________________________________ Lipscomb ID: L_____________________________________________________________
Name _____________________________________________________________________________________________________________________________
Last
First
Middle
Address: ___________________________________________________________________________________________________________________________
Street Number and Street Name
Apt./P.O. Box Number
____________________________________________________________________________________________________________________________________
City
County
____________________________________________________________________________________________________________________________________
State
Zip Code
Home Telephone
Work Telephone
Please outline in detail below your proposal for using the Ayers Leadership Fellow position within your district. Be specific about
the agreement you and your district have established and the ways this opportunity will be used to benefit your district. Include
any funding, release time, additional responsibilities, and commitments that have been guaranteed upon your selection for this
program. Use additional pages if necessary.
Signature of scholarship applicant: ________________________________________________
Date:___________________________________________
Printed name of scholarship applicant:___________________________________________________________________________________________________
To be considered for the 2015 Ayers Leadership Fellows, this form must be submitted with a completed application packet by March,
31, 2015. For additional information, please contact kristin.baese@lipscomb.edu or 615.966.5173.
Certifying School Official:
As an official of __________________________________________________school/school system, I do with my signature below certify that
____________________________________________________ has been offered the above opportunities in our district upon selection as a 2015 Ayers
Leadership Fellow.
Signature of Official:_____________________________________________________________Date:___________________________________
Printed name and position of official:___________________________________________________________________________