Application
2009 Governor’s Institute for Early Childhood Educators
Keystone College
July 26-31, 2009

The registration form must be completed by the individual applicant. "Strengthening the Achievement of Young Learners through Data Driven Decision Making” is the title of this year's Early Childhood GI. During the weeklong Governor’s Institutes, early childhood practitioners will learn how to effectively observe the interactions of students, record these observations, gather information in other ways, analyze and interpret the collected data and use the data to develop effective lessons and monitor the progress of the young children they serve. Participants will be reminded of the linkage among Child Development, Curriculum, Standards, and Assessment.

*** = Required

Personal Information

Name:

 ***

Home Address:

 ***
City:*** State: ***Zip:***

Home Phone#:

Cell Phone#:

Pager#:

Home Email:

 ***
Work Information

Place of Employment:

Current Position:

Work Address:
City: State: Zip:

Work Phone#:

Work Email:
   
1.) Why do you wish to participate in the Early Childhood Governor’s Institute?***

 
2.) Have you ever attended an Early Childhood Governor's Institute?
Yes No
If yes, how many years have you attended an Institute?
1 year 2 years 3 years 4 or more years
 
 3.) In which of the following programs are you involved?
Pre K Counts Head Start STARS
School District Licensed Private Nursery School
Other (please indicate)
 
4.) If you are involved with the STARS program, at what STARS level is your site?
STAR 1 STAR 2 STAR 3 STAR 4
 
5.) With which age/grade level of children do you work?
Birth to 1 year Ages 1 to 3 Ages 3 to 5 Ages 5-12
 
6.) In which setting do you work with children?
ECE center Pre-K Counts Program Head Start Early Intervention
Kindergarten Grade One Grade Two Grade Three
 
7.) Are additional individuals attending the Governor’s Institute as your team members?
Yes No
List Names Below

 
8.) Indicate the name of the administrator on your team:
 
9.) Do you understand that this is a residential weeklong Institute?
Yes No
 
10.) Do you understand that you will be residing in a college dormitory as part of a team and housed 3
with a (team) roommate?
  Yes No
 
11.) Do you understand that single room preference is generally not an option for residency at this institute?
Yes No
 
12.) If you are accepted, do you agree to participate according to these guidelines?
Yes No
 
13.) Do you understand that to receive two college credit hours the following requirements must be
fulfilled?
  • Mandatory attendance and participation at all the events during the weeklong Institute
  • A completed and submitted Action Plan at the close of the Institute
  • Two follow-up Action Plans submitted by due dates of November and April

Yes No
 
14.) If accepted, do you agree to abide by these guidelines?
Yes No
 
15.) If this Institute becomes fully enrolled, would you be interested in attending another
Early Childhood Governor’s Institute?
Yes No
 
16.) If yes, indicate the site you are interested in attending
Juniata College (July 13-18, 2009)
St. Vincent College (June 29 – July 3, 2009)
 
17.) How do you plan to share the information gained at this Governor’s Institute?
I will share the information with staff at my work site.
I will share information with families at family meetings.
I will share the information at schools in my district.
I will share the information with my legislators.
Other (please indicate)