Ambassador Application Form

Personal Information
First Name:
Last Name:
Home Address:
City:			Zip:
Home Phone:
Primary Email Address:
Alternate Email Address:
Professional Information
Title/Position: Teacher Literacy Coach/Reading Specialist Intervention Specialist School Administrator Curriculum Coordinator/Other District Leader Education Consultant Retired Teacher Other If "other" then please specify:
County Where You Work: Adams Allen Ashland Ashtabula Athens Auglaize Belmont Brown Butler Carroll Champaign Clark Clermont Clinton Columbiana Coshocton Crawford Cuyahoga Darke Defiance Delaware Erie Fairfield Fayette Franklin Fulton Gallia Geauga Greene Guernsey Hamilton Hancock Hardin Harrison Henry Highland Hocking Holmes Huron Jackson Jefferson Knox Lake Lawrence Licking Logan Lorain Lucas Madison Mahoning Marion Medina Meigs Mercer Miami Monroe Montgomery Morgan Morrow Muskingum Noble Ottawa Paulding Perry Pickaway Pike Portage Preble Putnam Richland Ross Sandusky Scioto Seneca Shelby Stark Summit Trumbull Tuscarawas Union Van Wert Vinton Warren Washington Wayne Williams Wood Wyandot
School/Institution Name:
School District:
Work Phone:
School/Teaching Information
Subjects Taught: English Language Arts / Reading Mathematics Science Social Studies Other If other, specify:		Grade Levels Preschool Elementary Middle School High School Higher Education
Membership in Professional Associations:
References
Name:		Title:
Place of Employment:
Phone:		Email:
Name:		Title:
Place of Employment:
Phone:		Email:
Personal Statements
Why are you applying to be an ORC Ambassador?
What talents, experience, and/or perspectives will you bring to the ORC Ambassador Program?
Please describe how you have used ORC in your work.
If you have conducted any ORC presentations or presentations that included ORC resources, please describe them.

Important Reminder: If you are a K-12 teacher, please remember to print the Statement of Administrative Support and give it to your administrator or department chair to complete. It must be either faxed or mailed to ORC. If you have any questions, please contact us.