2018Study of the United States Summer Institute for
Secondary School Educators

Application Form

Please email completed applications to:

Application deadline: December28, 2017

Personal Information:

Family Name / First Name / Patronymic / Title (Dr./Mr./Mrs./Prof.)
(AS IT APPEARS IN YOUR PASSPORT)
Date of Birth (MM/DD/YYYY) / City of Birth / Country of Birth
Country of Residence / Country of Citizenship
Home Address / Postal Code
Cell phone / Home Telephone / E-mail
(NOTE: Please include the telephone code for your city or region.)
Male / Female
Medical, Physical, Dietary or other Personal Considerations:
Professional Information:
Current Position / Title
Organization Name
Address
City
Telephone/Cell phone / Fax
Work experience, most recent first:
Organization/Employer / Position/Title / Dates of Employment
Education, Academic and Professional Training, most recent first:
Degree Earned/Fields of Specialization / Institution / Year Earned
Active professional memberships:
Short List of relevant publications (maximum 10 publications). Publications should include the publication year, type of publication, title, and publisher. All foreign titles should be translated into English. To identify the publication type, please choose from among the following options: 1) book; 2) edited volume (as primary or co-editor); 3) book chapter; 4) journal article; 5) newspaper/online article; 6) conference/university/government working paper.
U.S. Travel:
Purpose / Date / USG-funded
Yes No
Yes No
Yes No
Yes No
  1. 17.
/ Family Residing in the United States. Please list any immediate family members who are currently residing in the United States, including city and state:
English Proficiency:
Reading: / Excellent / Good / Fair
Writing: / Excellent / Good / Fair
Speaking / Excellent / Good / Fair
  1. Professional responsibilities. Please discuss your professional responsibilities in greater detail, including research interests, administrative responsibilities, (e.g., curriculum design), and/or other pertinent information.

Recent courses taught - Pleaseinclude: a) course title; b) level of students (PhD, MA,BA); c) classroom hours per semester; d) number of students per class; and e) U.S. Studies content (%).

Current Extra-Curricular/Co-Curricular Activities – Please include: a) activity; b) position/title; c) dates; d) description of duties.

Other Potential Outcomes – Pleaseselect all of the likely potential outcomes that might result from your participation in this institute: 1) update existing course; 2) create new course; 3) create new degree program; 4) redesign schoolcurriculum; 5) redesign national curriculum; 6) new research project; 7) new publication; 8) professional promotion; 9) government or ministry policy; 10) new professional organization; 11) new institutional linkages; 12) raise institutional profile. Please explain each point marked.

  1. Personal Essays (Limit 250 words).

Please discuss why you wish to participate in this program. Include your current personal teaching philosophy, how your participation in the Institute will enhance your work, improve education about the United States in your community, and help you achieve the“Other Potential Outcomes” you have checked above.

Applications without essays will not be considered.