State House Express

STATE HOUSE EXPRESS

2016 – 2017APPLICATION FORM

Teachers may submit applications for the State House Express program to Eagleton at any time during the academic year (September-June). Grant awards will be made on a rolling basis with decisions made as soon as the applications are received. Grant award notification will be sent via email, so please make sure to include a correct email address. If no email is listed, notification will be sent via regular mail.

Eligibility criteria:

• Students must be in grades 6-12.
• Tour group must consist of a minimum of 25 students.
• All tours must be scheduled and completed during the 2016-2017 academic year (September 2016-June 2017).
• All teachers of students in grades 6-12 in public and private schools are encouraged to apply, including those who have received awards in the past. Individual teachers are eligible each year. In special circumstances, separate grants may be awarded to different teachers in the same school.
• Other school groups or organizations who do not meet the exact criteria specified above may also apply and will be considered on a case-by-case basis.

Please click on each grey box and type info to complete this form.All fields must be filled out in order for your application to be reviewed.

Name of Teacher: Application Date:

Name of School:

School Address:

City: State: NJ Zip:

School Phone:School Fax:

County: Name of Principal:

Teacher Home/Cell Phone:Legislative District:

Teacher e-mail for grant notification:

Please put an X in the appropriate boxes below:

School: Middle School High School # of Students and adults in tour group:

Grade: 6th 7th 8th 9th 10th 11th 12th

Class Type: Government History Civics AP Class Other:

Explain why you want to bring your class to visit the State House:

How did you hear about the State House Express Program?

Have you previously applied to the State House Express program?

Yes No If yes, please specify academic year(s):

Have you previouslyreceived a State House Express grant?

Yes No If yes, please specify academic year(s):

All applicants must comply with the section below in order to receive the grant. First time applicants must also submit a completed Substitute W-9 form, which can be downloaded from the Eagleton website.

1. The award check will be sent to the requesting teacher. All checks will be issued by Rutgers University and should be received within three weeks from the date Eagleton is notified of your scheduled tour date. If you have not received your check after 30 days of notification, please contact Gloria Minor at Eagleton.

2. It is the Teachers responsibility to contact the Tour Office at the New Jersey State Legislature’s Office of Legislative Services (609-847-3150) to schedule the date of your tour. When you call, tell the office that you want to schedule a tour through the “State House Express” program. School name on application and tour reservation must be the same. Tour availability depends on the legislative calendar so please have preferred and alternate dates available.

3. Submission of this application is considered confirmation that the teacher has permission from the proper school authorities to take students on this field trip.

4. Eagleton will verify all State House Express tours with the Office of Legislative Services Tour Office. If, for any reason, you accept the grant but are unable to schedule and take the tour between September 2016 and June 2017, the full award amount must be promptly returned to the Eagleton Institute within the current academic year so that another school can be given the opportunity to participate.

Please initial in the box below acknowledging that you have read and understand this important information:

Please return the completed application via email, fax or mail to:

Gloria Minor

State House ExpressPhone: (848) 932-8750

Eagleton Institute of PoliticsFax: (732) 932-6778

Rutgers, The State University of NJe-mail:

191 Ryders LaneWeb:

New Brunswick, NJ 08901-8557

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