California Physical Education-Health Project
Costa Del Sur Site (CDS) at Cal Poly, San Luis Obispo
Application for 2002/2003:
CDS expects to extend invitations to 10-15 new participants.
Submit this completed application form, with appropriate signatures, by 5 p.m., April 26th, 2002
Copy and paste into a word processor to regain lost formatting
A. Personal Information (Please print or type).
Name: Soc. Sec. #:
School/Instit.: Dist./County:
Preferred Address: City/State/Zip:
Home Phone: ( ) Work Phone: ( )
FAX: e-mail:
Optional - 1. Race/Ethnicity: 2. Gender: Male _____ Female _____
Application Preference/Strength (circle one): Health/Health Education Physical Education
Current Job Title: _____________________________________________________________
Current Assignment (including grade level): ___________________________________________
B. Educational Background: Please list all degrees (e.g., B.A., M.S.) and certificates (e.g., BCC, SB 1969, CLAD/BCLAD, LDS, Special Education, Adapted, etc.) earned.
Degree/Certificate Institution Area of Study Date Awarded
1.
2.
3.
C. Experience as a Health Professional,Teacher of Health Education, and/or Physical Education
Number of years in the above profession: Grade level(s) taught: ______________
Please list courses or units in both disciplines which you have taught:
Health and/or Physical Education Courses/Units Taught Grade Level Dates
1.
2.
3.
4.
D. Honors: Please list any professional honors.
_____________________________________________________________________________
_____________________________________________________________________________
(over)
F. Personal Statement
Please type (maximum of 1 page to be attached) a personal statement describing the strengths and possible needs you would like to address at your site in terms of factors that will increase student learning.
G. Applicant's Statement of Intent to Participate if Selected
If selected, I understand that my participation in Costa del Sur will include the Orientation at Cal Poly, San Luis Obispo, May 11th , 2001, the Summer Institute, at Cal Poly, San Luis Obispo, July, 14-25, 2002, and two retreats (Fall and Spring � dates to be determined by the participants).
______________
Signature of Applicant Date
To be completed by the site administrator:
The Administrators of the Subject Matter Project requests that we identify the following data:
1. Please indicate the placement of your school in terms of SAT 9 or API scores.
Math : Top 60 percentile Lower 40 percentile
Reading : Top 60 percentile Lower 40 percentile
2. I support this employee for the California Physical Education-Health Education Subject Matter Project, Costa del Sur site. If the applicant is selected, this school district/institution will provide a substitute/release time for two follow-up sessions during the 2001-2002 academic year.
________________________________________ _________________
Signature of Principal/Site or Immediate Supervisor Date
SUBMIT YOUR APPLICATION TO: Dr. C. Andrea Brown, (Director, Costa Del Sur)
Physical Education and Kinesiology Department
Cal Poly State University
San Luis Obispo, CA 93407
Phone: (805) 756-2198 Fax: (805) 756-7273 Email: [email protected]
Application Deadline: 5 p.m., Friday, April 26th, 2002