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APPLICATION FORM 2005-06 This page must be printed, filled out, signed, and sent to your District Representative Name________________________________________________________________________________ School District________________________________________________________________________ School_______________________________________________________________________________ School Address________________________________________________________________________ Subject Area (if applicable)________________________________Grade level______________________ Home Phone__________________________Email___________________________________________ I would like to be a participant in the Teaching American History Program at the: _______Full Participation level _______Half Participation level _______Partial Participation level I have read and agree to the "Requirements and Benefits for Participants in Teaching American History." _________________________________ _________________________Signature /Date Please return to your District representative: Athol-Royalston – Anna Garbiel, 978-249-2400; Erving/U#28 – Linda Driscoll, 413-423-3337; Franklin Tech – Terry Dun, 413-863-9561; Frontier/ U#38 - Dr. Diana Campbell, 413-665-1155; Gill-Montague – Kevin White, 413- 863-9326; Granby - Jim Pietras, 413-467-7198; Greenfield - Dr. Joyce Mehaffey, 413-772-1313; Mohawk Trail - Dot Lyman, 413-625-0192 x 31; Orange-Mahar - Kelli Gervais, 978-544-0018; Pioneer Valley - Patsy Casella, 413-498-2931; Ware - Gail Lucey, 413-967-4271 x20 If you do not have a FCPDC representative, please contact Dr. Barbara Mathews, Director, Teaching American History, at 413-774-7476 ext. 15 Priority will be given for applications received by July 15, 2005 District Representatives: please mail or fax to: Karen Kappenman, PVMA, 10 Memorial St., Deerfield, MA 01342, Fax: 413-774-5400 |
