Facilitation of Adult Learning Application Session Dates: December 2 – 3, 2014 Deadline: October 24, 2014 Fees: There is a $500 fee to help defray the cost of training materials, meals, and one night of lodging per participant. See the signature page for billing information. There are no refunds for cancellations after November 7th. If your school is part of our SSP Program, this fee is included in your budget. Lodging/Meals: Lodging is provided on Tuesday, December 2nd only. Meals are provided during the session. Guests and pets are not allowed to accompany you during your stay. Location: Winthrop Rockefeller Institute, Petit Jean Mountain (www.livethelegacy.org) Day 1: 10:00 am – 8:15 pm Day 2: 7:30 am – 3:00 pm Application Date: ________________________ You will receive a confirmation e-mail within 1-3 business days of submitting your application. If you do not receive an e-mail, please contact Becca Bertram at beccab@uark.edu or 479-575-6708. Due to the number of applications received, completing this application does not guarantee a slot. INDIVIDUAL INFORMATION I have applied to Facilitator Training before: YES __ NO __ I have attended another ALA Institute: YES __ NO __ FIRST NAME: PREFERRED NAME (if different): LAST NAME: Please indicate any special needs: SCHOOL INFORMATION SCHOOL DISTRICT OR ORGANIZATION: SCHOOL OR DEPARTMENT: STREET ADDRESS: CITY: COUNTY: PHONE: WORK E-MAIL: POSITION: NUMBER OF YEARS IN EDUCATION: STATE: CO-OP: ZIP CODE: Please answer the following questions in the space provided. Why is it important for you to participate in the Arkansas Leadership Academy’s Facilitation of Adult Learning? What experience do you have in facilitating adult learning (Professional Development, Meetings, etc.)? What specific content and/or skills do you hope to gain from this training? COMMITMENT: APPLICANT If selected to attend Facilitation of Adult Learning, I understand I am making a commitment to examine and improve my facilitating skills in order to improve myself and all learners, adult and children, in my system. In order to be considered for this training, I agree to participate in both days. APPLICANT SIGNATURE ___________________________________________ DATE ________________________ PRINCIPAL/SUPERVISOR (please print): ___________________________________________________________ If the above applicant is selected to attend Facilitation of Adult Learning, I commit to support him/her in this endeavor. I understand attendance is mandatory for both days of the institute. SIGNATURE _____________________________________________________ DATE ________________________ E-MAIL ADDRESS ______________________________________________________________________________ BILLING INFORMATION The University of Arkansas business office will send out invoices shortly after October 31st. Please indicate below the point of contact for your invoice. A PO# is required for acceptance into this training. If your school is part of our SSP Program, you do not need to fill out this section. PO#: ________________________________________________________________________________________ NAME/OFFICE: ________________________________________________________________________________ STREET ADDRESS: _____________________________________________________________________________ CITY/STATE/ZIP: _______________________________________________________________________________ PHONE NUMBER: ______________________________ EMAIL: _________________________________________ Contact: Becca Bertram 479-575-6708 (office) 479-236-0570 (cell) beccab@uark.edu Fax to: 479-575-8663 Mail to: Arkansas Leadership Academy 346 North West Avenue, Room 300 Fayetteville, AR 72701