Teachers In Residence Application

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

Please DO NOT hit the ENTER key when filling out the form, or the form will be sent prematurely.

You may use the TAB key to move from field to field.

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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Rimrock Foundation | 1231 North 29th Street | Billings, MT 59101
(800) 227-3953 | (406) 248-3175