Educator Mini Grants Application Name* First Last Birthdate* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*FaxEmail* Certifications Awards or Commendations Club/Organizations Memberships Employer InformationSchool or Education Center Name* Strret Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Fax Email* Number of Years Employed* Answer The Following QuestionsWhat percentage of your student population is considered at-risk? Please explain.*Why did you personally choose the education field for your vocation?*What strengths do you possess that will facilitate the implementation of an award?*What is your greatest challenge as an educator?*What is your student population’s greatest challenge?*For what are you seeking this grant?*Please provide a breakdown of costs for your request. (Maximum $250)*How would this grant impact the lives of your students?*What milestones will be applicable in the case of an award?*What plans do you have to attract additional funding to sustain or grow this initiative?*What community support exists to support this effort?*Do you anticipate any adverse conditions in the case of an award?*Reference InformationPersonal Reference #1Name* First Last Relationship* Email* Phone*Personal Reference #2Name* First Last Relationship* Email* Phone*Professional Reference #1Name* First Last Company* Title* Email* Phone*Professional Reference #2Name* First Last Company* Title* Email* Phone*Our PolicyIt is the policy of The Rita Langworthy Foundation, Inc. to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.Agreement* By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am approved for funding, any false statements, omissions, or other misrepresentations made by me on this application will result in my immediate repayment of funds dispersed.
