Environmental Learning Institute & Woodrow Wilson National Fellowship Foundation

2004 TORCH
Application for Admission

Environmental Learning Institute
5710 South Freeman Road #4
Tucson, AZ 85747 USA

Phone: (520-731-3374) E-mail: silverberg@alum.mit.edu

How to apply:

1. Complete the Application Form. Give the Reference Form to a supervisor (e.g. principal, dean, professor, manager) who is well acquainted with you and your teaching or work. Please submit the Application and Reference Form. You will be notified of your acceptance within a few weeks.

2. If financial assistance is required in order to attend the course please complete the TORCH Educator Partial Fellowship Application and include this with your application and reference form.


3. Within 10 days of your acceptance, submit your $150 non-refundable deposit by check with the Participant Registration Form. Please make the check payable to Environmental Learning Institute. (or use www.paypal.com to silverberg@alum.mit.edu) An email receipt will be sent to you.


4. Give the Medical Form to your health care provider. Ask them to complete it and return it to you.


5. Read and sign the Liability Waver.


6. Return the Medical Form and Liability Waiver to ELI not less than 6 weeks prior to the course start date.


7. The balance of the Share of Cost (SOC) fee is due 6 weeks prior to the course start date. Please make your check payable to Environmental Learning Institute. (or use www.paypal.com to silverberg@alum.mit.edu) An email receipt will be sent to you.


8. Please let us know your arrival information for the course rendezvous (airline, flight number, etc.)


I am applying to the following TORCH course:

Title:

Dates:

Will you be participating in the course for credit and what type of credit will you register for? Additional fees are required for credit. (graduate-level relicensure hours or graduate science hours; please circle)

PERSONAL INFORMATION

Name:


Mailing Address

Street:
City:
State:
Zip Code:
Phone:
E-Mail:

Permanent Address

Street:
City:
State:
Zip Code:
Phone:
E-Mail:

School:
Teaching Position:
Years teaching:

Passport Information
Do you have a passport?
What is the number?
What is the expiration date?

Education

College/University Name:
Graduate School Name (if applicable):
Date of Graduation:
Science Courses Taken:

Additional Information
Name of person to contact in case of emergency:
Telephone #:
Address:

Experience and Interests

Extracurricular activities/clubs or organizations:
Pre- and In-service professional development programs in which you have taken part:
Outdoor/camping experience:
Hiking experience:
Backpacking experience:
Travel experience (when, where, with whom, how long):

Please briefly (not more than a few paragraphs, attach additional page) explain what your learning objectives are by participating in this TORCH course.

I have read the WWNFF-sponsored/Environmental Learning Institute TORCH course description, syllabus, proposed itinerary, personal equipment list, personal clothing list, medical form, liability waiver. I feel that I understand and would enjoy and benefit from the academic and professional development experience they describe. I certify that all information I have provided on this form and in the other required forms are correct and accurate to the best of my knowledge.


Applicant signature:
Date: