Teacher Creativity Fellowship Program 2011

Teacher Creativity Fellowship Program 2010

Acrobat PDF viewer
software is required
in order to view
download documents
from this Web site.
Information about
Adobe Acrobat
software is available
at http://www.adobe.com/

TEACHER CREATIVITY FELLOWSHIP PROGRAM
Personal Information Form

Legal Name
(as reported to IRS)

First Name: *

Middle Initial: *

Last Name: *

Street Address
or PO Box

City

State

ZIP code

Home Telephone
(area code and number)

E-mail

Date of Birth
(optional)

Number of Applicants

Employing School Corporation
(if applicable)

Employing School Name

School Street Address

School City

School State

School ZIP code

Employing School Telephone Number

Educational Background

	Length and Nature of Teaching Experience: (begin with most current position)
Dates*	School and Subject Area*
Amount Requested	*
Other Amount	*
Current Teaching Position	*
Grade Level	*
Subject Area	*
How did you hear about this program?	*

* indicates form field is required in order to complete registration.

If you have specific questions about the program or application procedure, you may contact Lilly Endowment via e-mail: teachercreativity@lei.org