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2011 Educator Application Form
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Required
GENERAL INFORMATION
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Name:
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Title:
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School/Program:
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Address:
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City:
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State:
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Zip:
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Phone:
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E-mail Address:
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Please check one:
Skills for Growing
Skills for Adolescence
Skills for Action
Combination (specify)
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Grade levels included
SCHOOL/LESSON INFORMATION
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Demographics of school:
Rural
Urban
Suburban
Percent low income
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What was your initial goal for implementing Lions Quest?
(1500 character max with spaces)
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Course of study or program description for Lions Quest implementation:
(1500 character max with spaces)
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Number of students involved and grade level:
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Number of LQ lessons used and implementation schedule:
(2000 character max with spaces)
OBJECTIVES
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List the overall objectives of your Lions Quest implementation and program goals:
(2500 character max with spaces)
DESCRIPTION
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What is your personal philosophy of teaching and how has Lions Quest affected this philosophy?
(1500 character max with spaces)
Give specific examples of activities you have used to implement the Lions Quest program components, as applicable:
Curriculum (describe implementation model used and units, lessons taught):
(2000 character max with spaces)
School Climate (describe the leadership and process that is used):
(2000 character max with spaces)
Service-Learning
(2000 character max with spaces)
Family Involvement
(2000 character max with spaces)
Community Involvement
(2000 character max with spaces)
EVALUATION
Describe any formal or informal evaluation which demonstrates the effectiveness of your Lions Quest implementation as it relates to your goals. (Any accomplishments, acknowledgements or awards should be mentioned in this section)
(2500 character max with spaces)
RESULTS
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Note all outcomes such as positive changes in behavior or academic performance, community involvement, school/classroom/program improvement, and increases in attendance or graduation rate.
(2500 character max with spaces)
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