Documents
Resources
Learning Center
Upload
Plans & pricing Sign in
Sign Out

ANKIT CHANDRA

VIEWS: 20 PAGES: 9

									                                  Fulbright Study Tour for Teachers
                                     Egypt and Tanzania:123213
                              Contemporary Islam and Muslim Communities
                                         June 30-July 29, 2009
               (Fulbright will only notify us of funding in late winter. Until then, the trip is likely but not
                                                        definite.)
              Led by Harvard’s Center for Middle Eastern Studies & Boston University’s African Studies
                                                          Center

Application Form
Biographical Information

Name of
Applicant:_______________________________________________________________
_____________________
Mailing Address:
________________________________________________________________________
________________________________________________________________________
________________________________Zip_______________________
Home Phone:
(______)_______________________Email_____________________________________
Work Phone:
(______)________________________Email____________________________________
School: ______________________________________________________________# of
years here___________________
School Address:
________________________________________________________________________
________________________________________________________________________
________________________________Zip_______________________
Grade(s)/subject(s) taught (if appropriate, specify courses taught):
________________________________________________________________________
________________________________________________________________________
__________________________________________________________
Circle all that apply: Teacher Administrator Librarian Other
(specify)________________________________
Previous teaching experience (in the last 10 years):
School & Location Grade(s) Subject(s)
Years(s) from-to


Optional: Your racial, ethnic, or religious
background:________________________________


Essay
Please write a personal essay of roughly 700-1000 words, covering the following two
questions. (Use a 12-point size font and normal margins).

1. What project or topic do you envision as your focus while overseas and how does
it fit your work?
2. What in your experience or background will ease your adaptation to an unfamiliar
environment and an intense group living?
Experience
Feel free to use a separate sheet if necessary

Overseas travel:
Country                              Purpose of visit                         Length of stay
Year


Content on Africa (including Egypt) currently included in your teaching (indicate amount
of time spent, topics, and countries/regions):




Islam/Muslim communities currently included in your teaching (indicate amount of time
spent and topics):




Conferences and workshops/presentations (list topic of presentation, name of conference, and year)




Distinctions (List any honors, awards, recognitions, etc...):
Have you received a U.S. government educational exchange grant (Fulbright or other)? If
so, please list the country and year:



I certify that the information provided on this application is correct to the best of my
knowledge. I agree to the terms and conditions of the award if selected. I also agree, if
selected, to the following provisions:
To complete all project-related activities (a) the 2-day pre-departure orientation, (b) the
study tour, and (c) the 2-day follow-up program
To complete an individual project
To disseminate my African experience in and beyond the classroom



Signature:____________________________________________________________
Date:___________________
Name (Please Print):
________________________________________________________________________
__
To Department Head or Principal:

 agree to the release of
____________________________________________________________ for one school
day in the spring of 2009 for orientation and one in the fall of 2009 for the follow-up
program for the Fulbright Egypt and Tanzania study tour for teachers.

Position: ____________________________________________________________
Signature: ___________________________________________________________
Your Name: __________________________________________________________


                                 Fulbright Study Tour for Teachers12
                                         Egypt and Tanzania:
                              Contemporary Islam and Muslim Communities
                                         June 30-July 29, 2009


Letter of Reference
To be completed by the applicant:
Name of applicant: ____________________________________________________________
(Optional) I hereby waive my right to read this confidential recommendation, as provided in the
Educational Rights and Privacy Act of 1974.


Signature: ____________________________________________________________Date:
___________________


Instruction to the Referee

The applicant has applied to participate in a Fulbright-Hays Group Project Abroad program. The
program includes a two day orientation, an intensive month long program of study, travel and
curriculum development in Egypt and Tanzania and two follow-up days in the fall. It requires
ability to live and work closely in a group, travel in stressful situations, and to complete a project.
Upon her/his return s/he will engage in outreach to professional colleagues and to the
community. In a letter, please assess the applicant’s effectiveness as a teacher and especially as a
leader among his/her colleagues.We would like your assessment of the applicant’s ability to
complete a sound comprehensive project. Please address the applicant’s motivation and interpersonal
and group-living skills, adaptability to unfamiliar living conditions, and ability to withstand
stress.


If the applicant has signed Item 2 above, the confidentiality of this letter is assumed.

DEADLINE: February 20, 2009 (date the reference should be received)
Among approximately____ educators I have known in this profession in recent years, I would
rank this applicant as # ___. (1=poor, 2=fair, 3=good, 4=very good, 5=outstanding)

Signature:____________________________________________________________
Date:__________
____________________
Title:_________________________ Institution:
________________________________________________________________
Address:
______________________________________________________________________________
_________________
Phone: (_____)_______________________________________ Email:
______________________________________________
Please mail the completed reference to “Att: Egypt/Tanzania Program CMESOC 38 Kirkland
Street Cambridge, MA. 02138”




                               Fulbright Study Tour for Teachers
                                      Egypt and Tanzania:
                             Contemporary Islam and Muslim Communities
                                       June 30-July 29, 2009


                                Participant Agreement Form
PLEASE PRINT CLEARLY


INFORMATION

Name: ___________________________________________

Address: ___________________________________________

Email: ___________________________________________

Phone:                 Cell Phone:

Employer:_________________________________________________________________
Employer Address:
___________________________________________________________________________
________________________________________


Subject Currently Taught: ________________________________________

Years Teaching: _______________________________________

Grade Level of Teaching: ________________________________________
Date of Birth (MM/DD/YY): _____________


Citizenship: US Other _______
Name (as it appears in your passport): ___________________________

Passport Number: __________________________________

Passport Country: __________________________________

Passport Expiration: __________________________________




                     APPLICATION POLICIES: Read and initial each statement
    All application materials must be returned to the
   Outreach Center, CMES, 17 Sumner Road, Cambridge, MA. 02138

    I am aware of the application deadlines for the Study Tour


    The Study Tour reserves the right to request additional information
   from the participant (e.g., letters of recommendation, personal statement) in
   order to evaluate an application

    I have read and understand the attached Withdrawal/Cancellation Policy

    I understand that I am responsible for all non-recoverable costs associated with the program

    I understand that if accepted as a participant on the Study Tour I will act responsibility, will be a team
   player, and will accept the program leadership of the Academic Leader

    I am submitting this application to be a participant on the Study Tour. I accept the previously mentioned
   application policies.




   Participant Signature Date


Print Name
                                             WITHDRAWAL POLICY

Introduction: The decision to participate in the Study Tour involves a significant investment of
money and requires a commitment on the part of the participant to fully prepare and participate in
order to experience the program's full benefits. Those interested in participating in the Study Tour are
urged to plan carefully and to be completely familiar with the withdrawal policies before applying.

A participant withdrawing from the Study Tour at any time after applying and being accepted is
responsible for all non-recoverable expenses paid by the Study Tour.

Program Cancellation/Suspension Policies
If the US State Department issues an official recommendation to evacuate US nationals from Egypt
and/or Tanzania the program will be suspended or cancelled and:

 participants are required to return immediately to the US
   All

 Only recoverable program fees will be refunded

Study Tour participants are not entitled to any refund if and when there is a threat or an
outbreak of war




1




                             FULBRIGHT STUDY TOUR TO EGYPT AND TANZANIA
                                            WAIVER FORM
                              THIS IS A RELEASE OF LEGAL RIGHTS –
                            READ AND UNDERSTAND BEFORE SIGNING
Name of Participant:_____________________________________________________

Organizing School or Department: The Outreach Center, Center for Middle Eastern Studies,
Harvard University and Boston University’s African Studies Center

Purpose of Trip: Training and education development on the contemporary Muslim
communities in Egypt and Tanzania for future application in community and public
education

Destination(s): Egypt and Tanzania

Date(s): June 30-July 29, 2009

“Harvard” is understood to refer to President and Fellows of Harvard College, Harvard
University (including its constituent schools and departments) and its officers, employees,
agents, representatives, and instructors. “Trip” is understood to include all activities at
destinations, and all travel to and from such destinations.


In consideration of the Trip to a foreign country or countries arranged by Harvard,
Participant hereby acknowledges and agrees as follows:

1. Voluntary Participation. I hereby acknowledge that participation in this Trip is entirely
voluntary.

2. Risks of International Travel.

a. I understand that participation in the Trip and international travel involves risks.
These include, without limitation, risks involved in traveling to and within, and
returning from, international locations; foreign political, legal, medical, social and
economic conditions; different standards of design, safety and maintenance of
buildings, public places and conveyances; and local weather conditions. The
country or countries to which I will travel may have health and safety standards
that differ from those in the United States, and I recognize that I may be subjected
to potential risks, illnesses, injuries and even death. I have made my own
investigation of these risks, understand these risks and assume them knowingly
and willingly.

b. I acknowledge that in working, living and traveling in cities abroad, I may
experience problems associated with urban living, including increased crime,
pollution, high population density or standards of living and health standards that
are different from those to which I am accustomed in the United States. I2
acknowledge that it is my responsibility to take every precaution to safeguard my
health and to protect my personal belongings from damage or theft. I acknowledge
that Harvard recommends that I never travel alone, particularly at night. Being
alone, especially at night, may present additional danger to my safety and wellbeing.


c. I understand that Harvard assumes no responsibility for accidents, illnesses, or
disabilities incurred by me during the Trip, or for conditions I will experience in
during the Trip. Further, I understand that Harvard can make no representations
about the accuracy of information supplied by others who are not agents or
representatives of Harvard and over whom Harvard has no control. I acknowledge
that Harvard assumes no responsibility for my personal effects, either in transit or
at final destinations.

d. [Although Harvard is providing administrative assistance for the Trip,] Harvard’s
evaluation of the Trip has been solely on its academic merits. Among other
things, Harvard is not in the position to evaluate, and therefore has not evaluated,
whether the Trip will take place in a safe and secure environment. These are
judgments that I recognize I must independently make.

e. I have read and understood the information on the State Department website at:
http://www.state.gov/travelandbusiness about the country or countries to which I
am traveling, including the U.S. Department of State Consular Information Sheet
and the State Department Travel Warnings (if applicable). I have also reviewed
the CDC health advisory information relating to travel abroad found at
http://www.cdc.gov/travel. I understand that Harvard University Health Services
provides traveler information and information regarding inoculations at
http://huhs.harvard.edu/hls/HLSServices.htm.

f. For countries with U.S. State Department Warnings (Egypt and Tanzania, as of
Tuesday 9 December 2008, did not have a travel warning from the USDOS): [I am
aware that there is a current U.S. State Department warning about one or more of
the countries to which I am traveling, and I have read and understood this warning.
I acknowledge that I have knowingly and voluntarily decided to go forward with
my travel plans in connection with the Trip despite this warning. I also have read
and understood the U.S. Department of State Consular Information Sheet about
the country or countries to which I am traveling (available on the State
Department website at http://travel.state.gov).]


3. Health Insurance; Medical Care. I will carry valid and current medical insurance and have
a valid insurance identity card to bring. I have reviewed my coverage and have determined
that this insurance is adequate to cover injuries or illnesses that I may sustain while
traveling abroad. I will be solely responsible for payment in full of all costs of medical
care I may receive overseas.

4. Standards of Conduct. I recognize that I assume an important personal obligation to
conduct myself in a manner compatible with local laws and regulations, and with
Harvard’s policies for Trip participants. I promise to act responsibly and will become
informed of, and will abide by, all such laws, regulations and standards. I agree to abide
by any regulations or instructions which the leaders of the Trip may decide are necessary
during the Trip for my safety and/or comfort.

5. Travel Arrangements. I understand that Harvard does not represent or act as an agent for,
and cannot control the acts or omissions of, any host family, host employer,
transportation carrier, hotel, tour organizer or other provider of food, goods or services
involved in the Trip. I understand that Harvard is not responsible for matters that are
beyond its control, and that it cannot warrant the safety or convenience of the
circumstances under which I will be living or working.
6. General Release. Knowing the risks described above, I agree, on behalf of my family,
heirs and personal representative(s), to assume all the risks and responsibilities
surrounding my participation in the Trip. To the maximum extent permitted by law, I
release, hold harmless and agree to indemnify Harvard and its officers, directors, faculty,
staff, representatives, employees and agents, from and against any present or future
claim, loss or liability for injury to person or property which I may suffer, or for which I
may be liable to any other person, related to my participation in the Trip (including
periods in transit to or from my destination), resulting from any cause, including but not
limited to ordinary or gross negligence.




I certify that I am age 18 or older. I have carefully read and freely signed this Acknowledgement
of Risk and General Release Form. I understand and agree that no oral or written representations
can or will alter the contents of this document. I agree that this agreement shall be governed by
the laws of the Commonwealth of Massachusetts (excluding its conflict of laws principles),
which shall be the forum for any lawsuits filed under or incident to this agreement or the Trip.

Signed: _________________________________ Date: _____________

Participant Name (print) _______________________________

1st Emergency Contact Information             2nd Emergency Contact Information

Name: ______________________________ Name: ______________________________
Relationship: _________________________ Relationship: ________________________
Address: ____________________________ Address: ____________________________
________________________________ ________________________________
________________________________ ________________________________
Phone: _______________________         Phone: _______________________
Cell Phone: ____________________       Cell Phone: ____________________
E-mail:____________________                 E-mail: ____________________


If Participant is under age 18, the parent and/or legal guardian must sign below:
I, the undersigned parent and/or legal guardian of the Participant listed above (the “Participant”),
do hereby consent to his or her participation in the Trip. I, as the parent of the Participant and on
behalf of the Participant, release, hold harmless and agree to indemnify Harvard, and its officers,
directors, faculty, staff, representatives, employees and agents, from and against any present or
future claim, loss or liability for injury to person or property which I or the Participant may
suffer, or for which the Participant may be liable to any other person, related to the Participant’s
participation in the Trip (including periods in transit to or from the Participant’s destination),
resulting from any cause, including but not limited to ordinary or gross negligence.

Signed:________________________________ Date:_________________

Name (print):___________________________

								
To top