Contact Information

First Name *:

Last Name *:

Email Address *:

Daytime Phone:

Evening Phone:

Name of School *:

School Information

Address 1 *:

Address 2:

City *:

State *:

Zip *:

Subject and grade level of classes taught *:

Principal's Name *:

Have you ever received a One Class at a Time Award? (A teacher may only win the award once per school year.) *:
Yes
No

If yes, what year?:

Describe the proposed project or plan *:

Identify the needs/problems to be addressed, target population and number of people to be served by the project *:

Describe, in detail, the project goals and objectives *:

Evaluation: Describe how you will show that your project has achieved its goal(s) *:

Provide a timetable for implementation. (implementation must be within 90 days of receiving the Award) *:

Budget Necessary to make your project happen. It must be detailed and as close to $1000 as you can get *: