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2013-14 CTA ETHNIC MINORITY EARLY IDENTIFICATION AND DEVELOPMENT MEMBER APPLICATION

This form must be submitted by 5:00 pm on May 3, 2013.

Name:*

Address:*

City:*

Zip:*

Home Phone:*

School Phone:*

Cell Phone:

Home Email:*

Ethnicity:*

Affiliate Information:

Gender

District Employer:

Employment Category:

Years as CTA/NEA Member:

CTA Region:

Local Chapter/Association:

Your Local CTA UniServ Staff:

Your CTA Board Member:

Please indicate any positions you have held within CTA/NEA (including your local chapter):

Please indicate any positions or roles you have held in any Fraternal or Community Clubs:

Why do you want to be in this program?

Briefly describe how your acceptance in this program will benefit you and CTA:

Additional Information/Questions:

Referral Information

Did a CTA Leader or Staff Person complete a referral form on your behalf?

If so, please indicate who:

If selected, I understand and commit to the following:
In order to be an effective leader, I will work with CTA staff and leadership to advance my understanding and involvement in the organization.
As a participant in the program, I will be available to attend training opportunities and meetings after school.

Although this is a voluntary program, once accepted I will participate fully.

Acceptance to this program requires attendance at the Emerging Leaders Track at CTA’s Summer Institute held on the UCLA campus, Sunday, Aug. 4 through Thursday, Aug. 8, 2013 (attendance is fully funded by CTA).

Please check this box indicating that you have read and accept the above terms.

Please indicate your primary phone number. We will use this number to notify you.

Deadline for applications: Wednesday, May 3, 2013, 5:00 p.m. Participants will be notified by Friday, May 31, 2013.

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About CTA

2013-14 CTA ETHNIC MINORITY EARLY IDENTIFICATION AND DEVELOPMENT MEMBER APPLICATION

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