ADAPTOR APPLICATION
(Please type or print clearly ) DEADLINE: October 24, 1997 (postmark)
A. General Information
Applicant's Name
School Telephone
School Name /School District
School Address
(No.) (Street) (City) (State) (Zip)
Home Address
(No.) (Street) (City) (State) (Zip)
Home Telephone:
Supervisor's Name, Tel. & Address
B. Adaptor Program Information
Catalog Title of Developer Program
Program Developer's
Name Developer's School
Were you able to make direct contact with the developer teacher?*
If no, please explain:
Applicant's Contact with the Developer Teacher:
| Dates of Contacts | Types of Contacts(e.g. telephone,School visits) | Comments and/or Issues Discussed |
When do you plan to adapt this program in your class? Date:
What is the educational need for this program in your class/school?
What qualities of this program most impressed and interested you and why?
*NOTE: ONLY THOSE APPLICANTS WHO HAVE MADE DIRECT CONTACT WITH THE PROGRAM DEVELOPER CAN BE AWARDED THE GRANT.
How will this program be implemented into your regular program, teaching schedule, daily operations and curriculum? (Please explain detail .)
What materials would you need in order to adapt this program in your class? Please list below with approximate costs. (Total not to exceed $200.)
| Item Description | Approx. Cost |
| Total |
C. Applicant's Present Teaching Program:
| Subject Area(s) | Grade(s) |
| Total number of years teaching experience: |
Total number of students who will be involved in the adaptor program: (Base answers on your current enrollment.)
| Special (Explain |
Achievement levels and special groupings of the students who would be involved in the program: (Indicate the number in each category. Do not duplicate numbers. Your professional estimates are acceptable.)
D. Staff and Resources
What other staff members would be involved in the adaptation of the program? (e.g. paraprofessionals, resource personnel, etc.)
Total
Applicant's Name
What other resources does your class, program or school have to assist with the adaptation of this program? (e.g. equipment, instructional materials, community services, etc.)
Would you be able to visit the developer's school for consultation if IMPACT II provides funds for coverage by a substitute teacher?
| Would you be able to visit the developer's school for consultation if IMPACT II provides funds for coverage by a substitute teacher? |
| If no ,please explain: |
E. Administrative Support (This section must be completed by the school principal in order that the application be considered for a grant. )
support implementation of this program during the school year
| to |
Can the applicant be released to visit the developer's school for program consultation, if IMPACT II provides funds for coverage by a substitute teacher? Yes No
Can teachers and IMPACT II staff visit the adaptor's program on a limited basis with the prior approval?
If the adaptor's program is successful, will you be able to fund its continuance as part of the regular school budget next year?
Comments:
Principal's Signature___________________Applicant's Signature____________________
Please return completed application to:
BOCES Southern Westchester
Elissa Morgan, Director
2 Westchester Plaza
Elmsford, NY 10523