KENT STATE UNIVERSITY
Regents STARTALK Teacher Leadership Academy: Chinese, Russian
Director: Dr. Brian J. Baer / Co-director: Theresa A. Minick
(Program Dates: Sunday, July 5 - Tuesday, July 14)
Summer 2015 Application for Admission (Deadline: April 1)
Please TYPE
No admission fee is required.
Section 1
Legal Last Name: ________________Legal First Name_________________
Middle Name__________________________
Suffix (Sr., Jr., II, III, etc.)_____________
Previous Last Name ________________________________________
Social Security Number _____-_____-________
Birth date: Month _____
Day ____
Gender:
Male
Female
Year ___________
Have you previously applied to any campus of Kent State University?
Yes
No
If yes, list the campus, year, and term of previous application and KSU ID # ________
Section 2 Permanent Address and Phone
Permanent Street Address___.__
City: __________________ State: ______ Zip: _____
County: ________
Home Phone ( )________
Cell Phone (______)____________________________
Email Address _____________
Section 3 Personal Information
Are you a United States citizen?
Yes
No
If no, and you are a permanent resident, provide your country of citizenship, permanent
resident card number and date granted.
____________________________________________________
Are you an Ohio resident?
Yes
No
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Modern and Classical Language Studies * Kent State University * Kent, Ohio 44242
330.672.2150
Ethnic Category
Ethnic information is used for reporting purposes only. Please select one or more as appropriate:
__African American (Black)
__American Indian or Alaskan Native
__Caucasian American (White)
__Asian American or Pacific Islander American
Next of Kin: Relationship (Example-spouse):
__Hispanic or Latino
__Non-U.S. Citizen
___________________________
Name
_________________________________________________
Last Name
First Name
Middle
Permanent Street Address_________________________________________________
City___________ State ______ Zip ____ County ______
Home Phone (____)______________ Cell Phone (______)____________________________
Email Address _______________________
Have you ever been convicted of a criminal offense or have charges pending against you at this
time (other than minor traffic violations)?
Yes
No
Have you ever been dismissed, suspended or placed on probation by any other college or
university for a non-academic reason?
Yes
No
Section 4 Teaching Information
Name of School _________________________________
School District __________________________________
School Address
______________________________________________
Number and Street
__________________
Phone Number
_______________ _______________________
County
City
_______________
Zip
______
State
Language (s) you teach:_____________________________
Levels of Language:
_________________________________________
Years of Experience:
_________________________________________
Do you have licensure?
Yes ______
Name of University granting licensure ______ _
No ______
Year _________
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Modern and Classical Language Studies * Kent State University * Kent, Ohio 44242
330.672.2150
Section 5 Educational Background
Previous College Information
Complete previous college attendance. (Include degree programs as well as individual courses)
Institution
EXAMPLE:
Kent State University
City/State
EXAMPLE
Kent, Ohio
From - To
Month and Year
EXAMPLE
9/2010-5/2012
Degree Obtained
(if any) OR, if it was
just a course, type in
the name of the
course
EXAMPLE
M.A. Education
Section 6 Professional Development
List professional development experiences during the last 3 years (workshops / conferences / and
/ or other STARTALK programs)
Workshop /
Conference /
STARTALK program
EXAMPLE
OFLA IPA Workshop
Location
City/State
EXAMPLE
Hudson H.S., Hudson,
OH
Date(s)
EXAMPLE
Nov 2013
Brief Description
EXAMPLE
Integrated
Performance Assess.
Section 7 Narrative
Please type a paragraph explaining why you would like to participate in the
Teacher Leadership Academy.
(Include as much space as needed)
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Modern and Classical Language Studies * Kent State University * Kent, Ohio 44242
330.672.2150
Section 6 Applicant Signature
By my signature I attest to the fact that all information given on this application is complete and
correct. Any intentional
omission or falsification will result in denial of admission or immediate dismissal.
____ _____________
Applicant’s Signature
__________________
Date
Director: Dr. Brian J. Baer / Co-director: Theresa A. Minick
E-MAIL Applications to the address below:
EMAIL: tminick@kent.edu
OR mail to:
STARTALK Teacher Leadership Academy
ATTN: Theresa Minick
109 Satterfield Hall
Kent State University
Kent, OH 44242
Office Use Only
________ Accepted
________ Denied
Name of program if grant supported: __________________________________________________________________
Date Admitted in Banner: ______________________
Processor: ________________________________________
FLA Staff Signature: ________________________________________________________ Date:________________
Comments: ______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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Modern and Classical Language Studies * Kent State University * Kent, Ohio 44242
330.672.2150