OHIO STATE ORGANIZATION
ALPHA DELTA STATE OHIO EDUCATIONAL FOUNDATION (ADSOEF)
A. Margaret Boyd International Study – Ohio Fellowship
Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Chapter Name
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Induction Date
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Membership ID Number
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How are/were you involved in Delta Kappa Gamma at each level?
Involvement at the chapter level
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Involvement at the state level
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Involvement at the International level
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About the institution granting credit
Name of institution granting credit
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Address of institution
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Credit hours that will be awarded
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Cost per credit hour
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About You
Current professional position: If retired, give retirement date and last professional position.
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Educational background: Beginning with most recent, including dates, college/university, degree/certification/licensure/other.
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Professional Educator experience: Give dates, school system, subject(s) taught, and positions.
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If you have had previous international travel or study experience: Include dates, topics of study, geographic location of study, and travel organization/program.
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Philosophy of teaching statement: This statement will be given significant consideration in the selection process. Explain how you plan to use your International Travel and Study experience to impact the Society, your school district, and/or your community. (200-400 words)
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Signature
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Date form completed
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Month
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Day
Year
Date
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