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2012 13 CLC Scholarship Application by jA8v0P8

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									                                2012-13 Mission Scholarship Fund
The Heartland Community College Foundation and Challenger Learning Center would like to help teachers offset the
cost of participating in a simulated space mission. If you are interested in receiving mission funds via the Foundation,
please fill out the application below. Please be aware of the following:
               Each individual teacher requesting funding must fill out a separate application.
               Priority will be given to underserved schools, not previously participated in a CLC program.
               Schools receiving mission funds are required to send a teacher to a Teacher Training Workshop and
                  utilize CLC curriculum.
               Schools will provide transportation to bring students to CLC on scheduled dates.
               Failure to comply with all provisions of the grant award may result in forfeiture.

Teacher/Point of Contact Name:______________________________________________________________

School Name:_____________________________________________________________________________

Address:_________________________________________________________________________________
            STREET                                                         CITY              STATE      ZIP CODE
Phone: (      ) _____________          E-mail:________________________________________________________

Grade/Subject ___________________ Number of Students:___________ Age Range of Students: _________

CLC Program Name: __________________________________________ Amount of Request: ____________

Have you or your school previously attended a Challenger Learning Center program? ___________________

If yes, how many programs did you participate in and when? _______________________________________

________________________________________________________________________________________

Please indicate the following in regard to the mission participants (Optional):

Number of Boys __________             Number of Girls __________

Caucasian, Non Hispanic ____                  Black or African American ____                          Hispanic ____
Asian or Pacific Islander ____                American Indian or Alaskan Native ____                  Other ____

Percentage of students receive free/reduced lunch: __________

Percentage of students at or below poverty level: __________

Please attach a one-page maximum (typed, double-spaced) response to the following:

1. How will this activity enhance the classroom experience for the students involved?
2. What are the short term and/or long term educational goals this experience will fulfill?

__________________________ ____________                            _________________________ ____________
APPLICANT SIGNATURE                    DATE                        ADMINISTRATOR SIGNATURE              DATE

__________________________ ____________                            _________________________ ____________
DIRECTOR CHALLENGER LEARNING CENTER    DATE                        EXECUTIVE DIRECTOR OF FOUNDATION     DATE

								
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