SD 4-H Teens As Teachers Team Registration Registration Due: March 23, 2015 4-H Teens As Teachers (TAT) Teams may register as a school/organization/club. Teams consist of 2-8 youth. Team members must be high school sophomores, juniors, or seniors. Graduated seniors are not eligible. It is encouraged that ½ of the team consist of current 4-H members. Minimal costs may be incurred by teams to implement their 4-H TAT program. Group Information School/Organization/Club: ___________________________________________________ Adult Mentor/Supervising Teacher: _________________________ Street Address: ___________________________________ City: _____________________ State: ___ Number of Teens Participating: ____ ZIP: ______ Males: ______ Office Phone: _______________________ Emergency Phone: ____________________ Adult email: _________________________ Females: ______ Please list the number of participating teens involved in each of the following: 4-H ____ Afterschool Program Worker ____ FCCLA ____ FFA ____ Student Council ____ Youth Internship ____ Other: ____ Other: ____ Teen Teacher Information Name: ____________________________________ Name: ____________________________________ Address: __________________________________ Address: __________________________________ Phone: ____________________________________ Phone: ____________________________________ Email _____________________________________ Email _____________________________________ Name: ____________________________________ Name: ____________________________________ Address: __________________________________ Address: __________________________________ Phone: ____________________________________ Phone: ____________________________________ Email _____________________________________ Email _____________________________________ Name: ____________________________________ Name: ____________________________________ Address: __________________________________ Address: __________________________________ Phone: ____________________________________ Phone: ____________________________________ Email _____________________________________ Email _____________________________________ South Dakota State University, South Dakota counties, and U.S. Department of Agriculture cooperating. South Dakota State University is an Affirmative Action/Equal Opportunity Employer and offers all benefits, services, education, and employment opportunities without regard for race, color, creed, religion, national origin, ancestry, citizenship, age, gender, sexual orientation, disability, or Vietnam Era veteran status. © 2015 South Dakota Board of Regents, South Dakota State University Page 1 SD 4-H Teens Teachers Team Registration Name: ____________________________________ Name: ____________________________________ Address: __________________________________ Address: __________________________________ Phone: ____________________________________ Phone: ____________________________________ Email _____________________________________ Email _____________________________________ Partnering Group Information (This is the group teens plan to teach e.g. school, 4-H club, afterschool program.) Partnering Group & Contact Name _____________ Number of youth, the teens plan to reach (Refer to flyer to learn which age each content/curriculum is designed for.) Pre-K_____ K_____ 1st_____ 2nd_____ 3rd____ Number of adults (Teach SD curriculum only) _____ 4th_____ 5th_____ 6th_____ Individual Teaching Team Information (Teen teachers often teach in groups of two.) Teen Teacher Names HS Grade Teen Teacher Names 1. 1. 2. 2. Grade/Age will be teaching Grade/Age will be teaching Partner Group Teacher/Adult Partner Group Teacher/Adult Email Email Teen Teacher Names HS Grade Teen Teacher Names 1. 1. 2. 2. Grade/Age will be teaching Grade/Age will be teaching Partner Group Teacher/Adult Partner Group Teacher/Adult Email Email Teen Teacher Names HS Grade Teen Teacher Names 1. 1. 2. 2. Grade/Age will be teaching Grade/Age will be teaching Partner Group Teacher/Adult Partner Group Teacher/Adult Email Email HS Grade HS Grade HS Grade South Dakota State University, South Dakota counties, and U.S. Department of Agriculture cooperating. South Dakota State University is an Affirmative Action/Equal Opportunity Employer and offers all benefits, services, education, and employment opportunities without regard for race, color, creed, religion, national origin, ancestry, citizenship, age, gender, sexual orientation, disability, or Vietnam Era veteran status. © 2015 South Dakota Board of Regents, South Dakota State University Page 2 SD 4-H Teens Teachers Team Registration Select which Teens As Teachers content area your team would like to participate in (see brochure for descriptions): ____ Option 1: Character Education ____ Option 2: Science, Technology, Engineering & Math ____ Option 3: Nutrition and Physical Activity ____ Option 4: TeachSD Rank preferred training dates (1 = most favorable): April 7_____ April 8_____ April 9_____ May 2_____ May 9____ Written Program Plans Written collectively by your Teens As Teachers Team. Describe in 300 words what need(s) this program will help address in your community and how your group is prepared to carry out the Teens As Teachers Program. Include the following as applicable: administrative support, adult mentor support, partnering teacher/adult support, demographics, community involvement and partnership possibilities. Also, share how your team members will be able to adjust schedules to accommodate the hours dedicated to this program. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Submit your application via e-mail or fax by March 23 to: SDSU Extension Pierre Regional Center Aletha Scott, Senior Secretary [email protected] Fax: 605-773-8121 South Dakota State University, South Dakota counties, and U.S. Department of Agriculture cooperating. South Dakota State University is an Affirmative Action/Equal Opportunity Employer and offers all benefits, services, education, and employment opportunities without regard for race, color, creed, religion, national origin, ancestry, citizenship, age, gender, sexual orientation, disability, or Vietnam Era veteran status. © 2015 South Dakota Board of Regents, South Dakota State University Page 3
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