SVDP Juneau/Southeast Application

School Violence Prevention Demonstration Program
Tolerance and Civic Responsibility
2010-11 Application

First Name: *

Last Name: *

Which grade level do you teach?:

How many different students do you teach each day?:

School District:

School Name:

School Address:

City:

Home Address:

Home City:

Zip Code:

Home Zip Code:

School Phone: *

Home Phone:

Cell Phone:

Email Address: *

Email communication is a requirement for eligibility

Can you attend all the program sessions for the training location you have selected?:

Yes

How can this program benefit your classroom?:

Administrator Reference Name:

Provide the name of an administrator in your school as a reference

Administrator Reference Title:

Administrator Reference Phone:

By completing and submitting the application I understand that I am being considered for the program:

Applicants will be informed of their status with the program:

CAPTCHA

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Math question: * 3 + 1 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.