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APPLICANT CONTACT INFORMATION

Note: Teachers who have participated in KHOC three or more years in the past are not eligible to apply this year, unless they are applying together with newer, eligible teachers from their school.

* School Name:

* School District:

* School Street Address:

* School City:

* School State:

* School Zip Code:

Principal Name:

Principal Phone Number:

Principal e-mail:

* Lead Teacher 1 - Name:

* Lead Teacher 1 - Email:

* Lead Teacher 1 - Phone Number:

Lead Teacher 1 - Orientation Date:

Teacher 2 - Name:

Teacher 2 - Email:

Teacher 2 - Phone Number:

Teacher 2 - Orientation Date:

Teacher 3 - Name:

Teacher 3 - Email:

Teacher 3 - Phone Number:

Teacher 3 - Orientation Date:

Teacher 4 - Name:

Teacher 4 - Email:

Teacher 4 - Phone Number:

Teacher 4 - Orientation Date:

ABOUT YOUR SCHOOL

For the most recently available school year, please report your school’s:

* Percent of students eligible for Free and Reduced Price Lunch:

* Total Enrollment:

Breakdown of student body by Race and Ethnicity (should add up to 100%):

Latino ____%

African American ____%

Caucasian (non-Hispanic) ____%

Asian ____%

Pacific Islander ____%

Native American/
Alaska Native ____%

More than One Race ____%

Other ____%

LANGUAGES

* Percent of students who are English as a Second Language (ESL): ______%

* List the most common languages spoken by students in your school:

LOCATION

* Type of School (Check one):

	Rural
	Urban
	Suburban

Approximately how many students are in each of your applying classrooms this year?

* Teacher 1’s Classroom:

Teacher 2’s Classroom:

Teacher 3’s Classroom:

Teacher 4’s Classroom:

TEACHER QUESTIONS

How many years have you been an educator? (Please provide a response for each Teacher).

* Teacher 1:

Teacher 2:

Teacher 3:

Teacher 4:

How many years have you been a third grade teacher? (Please provide a response for each Teacher).

* Teacher 1:

Teacher 2:

Teacher 3:

Teacher 4:

How experienced and comfortable are you in leading classroom activities outdoors? (Please check one for each Teacher.)

SCHOOL PARTICIPATION QUESTIONS

On average, how many opportunities each school year do your classrooms currently have to participate in outdoor learning activities – either on or off site? Please provide brief examples of any such activities.

How many field trips do your third grade classrooms typically have each year? How many are in outdoors locations? Please provide brief examples of these trips.

PREVIOUS PARTICIPATION

Please enter the name of all teachers who have previously participated in KHOC and the number of years they participated.

* Lead Teacher Name 1:
(Previously Participated)

Teacher Name 2:
(Previously Participated)

Teacher Name 3:
(Previously Participated)

Teacher Name 4:
(Previously Participated)

By checking this check box and submitting this application, you agree to meet the expectations for participation in KHOC.

Would you like a copy of this application emailed to you?
Where can we send it to?
Please enter the email address here:

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