Teachers In Residence Application

Items marked with a * must be completed to process the form.

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Your Name: *

Home Address:

City:

State:

Zip:

Email:

Home Phone:

Work Phone:

School Name:

School Address:

City:

State:

Zip:

Position:

Grade Level:

Supervisor:

Please briefly describe why you are interested in taking part in the Teachers In Residence Program.

Have you served on any school-based chemical dependency prevention/referral teams or similar projects? If so please describe the group and your role in it.

What previous chemical dependency education/training have received?

Use this space to add any other relevant points you would like us to know when we review your application.

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