Parents for Public Schools Leadership Institute
Application Form 2012 - East Central MS - Meridian PLI
Name:
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Street Address
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City
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Zip
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Home Phone
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Area Code
Phone Number
Cell Phone
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Area Code
Phone Number
Phone Contact Preference
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Home Phone
Cell Phone
E-mail:
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Emergency Contact Name
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Emergency Contact Phone Number
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Area Code
Phone Number
Volunteer Experience
School Board
Yes
No
If yes, please indicate the role and dates served.
School Site Council
Yes
No
If yes, please indicate the role and dates served.
District Committee
Yes
No
If yes, please indicate the role and dates served.
School PTA/PTSA/PTO
Yes
No
If yes, please indicate the role and dates served.
Parents for Public Schools
Yes
No
If yes, please indicate the role and dates served.
Community Committee
Yes
No
If yes, please indicate the role and dates served.
Religious Institution
Yes
No
If yes, please indicate the role and dates served.
Scouts, Sports, Children's Activities
Yes
No
If yes, please indicate the role and dates served.
Other volunteer experience
Indicate the role and dates served.
Employer (current)
Position (current)
Children
Name
Age
Grade
Current School
School will attend in Fall 2012
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2
3
4
5
6
7
8
9
10
If you are accepted, what school do you plan to work with during the two year commitment?
Principal(s)
How did you find out about the PPS Leadership Institute?
Our funders require us to report on diversity of the participants. Please answer the optional question to assist us in the report.
Your race/ethnic origin
Your age
Gender
Female
Male
Please answer the questions below.
Tell us how you are involved in your community.
List and explain some ways you are involved in your child(ren)'s school.
Tell us about one time you demonstrated courage and were willing to question things that needed to be changed. What was the outcome?
Tell us one time you were creative in thinking about a solution to a problem.
The following list indicates leadership characteristics. Rate yourself on each:
Indicate your thoughts about your own leadership. Using the scale below, check the number that best represents YOUR response to each item.
Is enthusiastic, positive and people-orientated
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4 - always
3 - often
2 - sometimes
1 - rarely/never
Is solution and action-oriented
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4 - always
3 - often
2 - sometimes
1 - rarely/never
Is creative in thinking about solutions to problems
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4 - always
3 - often
2 - sometimes
1 - rarely/never
Is courageous and willing to question things needing to be changed; willing to take a risk based on solid information
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4 - always
3 - often
2 - sometimes
1 - rarely/never
Is honest and sincere in dealings with others; a good listener and communicator
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4 - always
3 - often
2 - sometimes
1 - rarely/never
Is fair-minded; treats all people with dignity and fairness; displays empathy
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4 - always
3 - often
2 - sometimes
1 - rarely/never
Is a team player who is able to build trust, delegate and empower others
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4 - always
3 - often
2 - sometimes
1 - rarely/never
Is dependable; sticks to commitments and follows them through to completion
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4 - always
3 - often
2 - sometimes
1 - rarely/never
List some issues or problems your school/school district is currently experiencing.
Issue/Problem #1
Issue/Problem #2
Issue/Problem #3
What could an organized group of parents in your school or community do to improve student learning? What could make that happen?
ATTENDANCE POLICY: Participants are required to attend all day and evening sessions and are strongly encouraged to take advantage of the overnight accommodations provided. Participants are expected to make childcare and other arrangements in advance in order to attend all sessions.
2012 INSTITUTE DATES: February 3 - 4, March 2 - 3, April 13 - 14, 2012
Hilton Garden Inn 109 US Hwy 11 & 80 Meridian, Mississippi
Each participant in the 2012 Parents for Public Schools- Parent Leadership Institute (PLI) should commit to attend all three two-day meetings and commit to design and implement one project in a public school or in the community that will impact public school children. To graduate from the PLI, you are expected to attend all sessions in their entirety. Participants are also expected to continue their involvement with the Institute for two years following the training sessions, to recruit other parents for the Institute, and to share their experiences with parent engagement in their community.
I understand the purpose and expectations of the Parents for Public Schools Leadership Institute and, if accepted, agree to devote the time, participate in the meetings, and conduct at least one parent project/activity in my community.
Signature (typing your name indicates that you understand the personal commitment.
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Date
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