/2012-2013-Page-application-form

WALTER HINES PAGE AND CHAUTAUQUA SCHOLARSHIPS 2012 – 2013

This application form must be typed and be accompanied by: - a covering letter - a recent professional reference/testimonial - a medical certificate providing evidence of fitness to undertake a strenuous tour - four passport sized photographs bearing the candidate's name on the back.

Name & title: Date of birth: Nationality: Home address, telephone number and e-mail (required):

School address, telephone number and e-mail (required):

Please state whether you are interested in applying for a Walter Hines Page Scholarship, a Chautauqua Scholarship or both.

Which Educational Association/Union’s scholarship are you applying for?

-Applications need to be made to the Union of which the applicant is a member

Position held:

Subjects taught:

Teaching experience in the last five years:

Education and qualifications gained:

Experience of overseas travel:

Experience of public speaking:

Do you have any contacts in educational institutions in the USA you wish to visit, please elaborate if necessary?

Can you confirm that your local authority and/or governing body will grant you the necessary leave of absence (Chautauqua = 2-4 weeks starting in the 4th week of June 2011, Walter Hines Page = 2 weeks between mid-October 2011 and mid-May 2012)?

Are you in a position to pay the remaining travelling and incidental expenses?

Please give the name and contact details of the referee who has provided your reference: Name: Address:

Email: Phone number: What are your reasons for applying for a Walter Hines Page scholarship?

Describe briefly what aspects of education you wish to study in the USA:

What are your aims and objectives for the Page scholarship?

How would a Page scholarship benefit your work, colleagues and union?

Is there any other information you would like to give?

Please continue on a separate sheet if necessary.

Where did you hear about the scholarship?

THIS APPLICATION SHOULD BE RETURNED TO YOUR UNION/ASSOCIATION BY 24 NOVEMBER 2011