E-Teacher Scholarship Program

E-Teacher Scholarship Program

Professional Development Distance Learning Program

for English Language Teachers

Please return the completed formby July 10, 2014to .

Instructions:

First, save the document to your hard disk.
Print out the form and read it carefully before filling it out.
Please fill in all required areas marked*.
Should you have any questions or need help for filling out this form, please callat 01 4234107Monday-Friday, 8am – 5 pm.

Please complete the below information:

*Have you ever participated in the E-Teacher Program? If so, which course and what year?

*Course: *participating year:

E-Teachercourses that are offered in 2014-2015 through University of Oregon:

Introduction to Pedagogy and Practices for Teaching English to Speakers of Other Languages (TESOL Methods)
Building Teaching Skills through the Interactive Web (Web Skills)
Practical Applications in Language and Learning Skills (PALSS) WINTER 2014 ONLY
English for Specific Purposes, Aligning Context with Practices and Materials (ESP)
Special Education and Differentiated Instruction in EFL Contexts (SpEd EFL)
Teaching English to Pre-teens and Teens (TEPT)
Teaching English to Young Learners (TEYL)
Summative and Formative Assessment in Language Learning and Teaching (Assessment)
Critical Thinking in Language Learning and Teaching (CT)

Learn more about these courses by visiting:

Please list the top three courses that you’d like to participate in (please note that you may not be selected for your first choice):

*1.

*2.

*3.

Personal data:

*Full name (First, Last):

*Title: Mr., Ms., Dr., etc.):

*Nationality:

Contact information:

*Street, number and apartment/suite number:

*City:

Postal code:

*Office telephone number (provide area code) and extension: (), ext. ()

Fax (provide area code): () ext. ()

*E-mail1:

*ConfirmE-mail1:

*E-mail2:

*Confirm E-mail2:

*Cell/Mobile phone:

Home telephone number (provide area code): ( )

*Current position: (please specify name of institution and starting date)

Dates / Position and institutional affiliation
from to date

* Responsibilities:

*Concurrent positions: (if any)

Dates / Position and institutional affiliation
from to date

*Previous positions: (provide dates starting with most recent and working back)

Dates / Position and institutional affiliation
fromto
from to
from to
from to
from to

*Publications or academic presentations:(provide the three most recent ones )

*Memberships:

*Educational background: (include dates, degree, academic institution, area of specialization)

Dates / Degree, area of specialization / Academic institution
from to
from to
from to
from to

*Reference:

*Name of referee:

*Office / Position:

*Phone / cell number:

*Email:

Please tick (√)

I am willing and able to participate in a graduate-level, distance-education, intensive academic program and to dedicate at least ten hours of my time per week for up to twelve weeks of instruction? (______)Yes (______)No

I commit to attending the course orientation session facilitated by U.S. Embassy / American Center /

E-Teacher Alumni of my country on my own (______)Yes (______) No

I commit to completing the course (______)Yes (______) No

I commit to giving at least one workshop, lecture, or course in order to relay or share the information and knowledge that I gain from taking the online course on my own. (______)Yes (______) No

Statement of purpose:
Please state why you are interested in participating in the E-Teacher program. Indicate what impact your participation in this program would have on your institution/region, and how you expect to put to good use, in the short or long term, the knowledge acquired in this course. (A thorough, clear response is decisive in the selection process, 500 words máximum)