Application

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The Central Western Zone  of the

New York State Retired Teachers’ Association

BARRIE FLEEGEL MEMORIAL ACTIVE EDUCATOR GRANT

APPLICATION FORM

Name______________________________________________________

Address____________________________________________________

City ___________________________     Zip_____________

Contact phone_(____)_____________ Email________________________

Place of employment  _______________________County______________

Professional responsibilities _______________________________________

 

Number of years in education ___________________________________

Name and contact information for your immediate supervisor or building principal

 

____________________________________________________________

Pursuing: (please check)

Permanent Certification ___    Certificate of Advanced Study ___

Master’s ___        Doctorate___

College or University at ___________________________________

 

Educational field _________________________________________

 

Please answer the following questions using a separate sheet of paper.

 

1. Have you received any financial assistance for graduate work? Explain any financial hardships or special circumstances.

2. During your career as an educator, have you received any special awards or recognition? List any exemplary achievements.

3. Have you been involved with unpaid extra-curricular activities or special assignments at your educational facility?

4. Are you involved in any community service projects?

5. Why did you enter the field of education and what are your long-term goals?

Please forward your completed application to: Ann Czajkowski  (annczajkowski@yahoo.com), 2311 Johnson Creek Rd, Barker, NY 14012 – postmarked by April 15th.