TEACHER HONOR PLAQUE APPLICATION

TEACHER HONOR PLAQUE APPLICATION

Payment of $100 is due before the plaque will be completed. Payment can be completed with this application or separately, as shown at the end of the form.
Information to be filled out by sponsor of Teacher Plaque
Sponsor's Name (as you want it to appear on the plaque)*
Sponsor's Phone & Email*
Do you want the plaque to be presented at a special day or time? If so, please provide details.
If no presentation is requested, do we simply hang the plaque in the Little White Schoolhouse?

yesOther
Name of plaque recipient
Present address, if living
If deceased, date of death

MonthDayYear
Date
If deceased, location of burial
What years did the recipient teach or work for the Caney School District?
What subjects did they teach or what job did they perform?
Coach any activity? Sponsor any group? Belong to any educational organization?
Graduated from high school where and when
Graduated from college where and when
Before coming to Caney, taught or worked where and for approximately what years?
After leaving Caney, taught and worked where and for approximately what years?
Spouse and children information:
Leisure time activities or hobbies of recipient
Favorite subject(s) to teach or some favorite aspect of teaching
Any special comments or recollections about their teaching career, particularly when employed by Caney school district.
Checks for $100 can be mailed to:
Caney Valley Historical Society
PO Box 212
Caney, KS 67333

Payment will also be accepted at the Historical Museum during business hours.

Payment can be completed in person or by phone.

Payment can be made with Venmo using the QR code below.
My Products
prevnext( X )
Teacher PlaqueOnline processing fee +$3.00
$103.00 Quantity

Total

$0.00

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

TEACHER HONOR PLAQUE APPLICATION

Information to be filled out by sponsor of Teacher Plaque