Governor's Scholars Program

Reactivation Request for the Summer of 2017

Name:

I wish to reapply I do not wish to reapply

MOST RECENT CAMPUS & POSITION
Please indicate the most recent campus you were assigned to and what position you held.
Campus:SELECT FROM LISTMorehead StateMurray StateNKUBellarmine Position Held: SELECT FROM LISTFacultyOffice StaffResident Advisor
2017 REQUESTED CAMPUS(ES) & POSTION(S)
Please keep in mind that each campus’ specific needs may change from year to year.
As a result, we ask that you indicate all campuses and positions to which you would be willing to be assigned.
2017 Campus(es): Morehead State University Murray State University Northern Kentucky University
2017 Position(s): Faculty Office Staff Resident Advisor

CURRENT CONTACT INFORMATION

Please indicate the most efficient, reliable ways that we may reach you between now and March. If you are not able to return to the GSP for the summer of 2017, please fill out this section and return the form so we have your updated information.
In January, your 2016 tax information will be sent to the mailing address that you provide here. Please plan accordingly.

Primary Phone: Other Phone:
Email:
Mailing Address:
City: State: ZIP:

ACADEMIC INFORMATION

Current Institution and subject(s) taught/Major:
Any information updates (new certifications, added Major, etc.):
I am willing to teach in a different discipline area, if needed. Please list:

SPRING RETREAT INFORMATION

I am aware that the Spring Planning Retreat will be held on March 24-26, 2017, for all returning personnel. I recognize that attendance at this retreat is mandatory and will be a condition of my employment, should I be invited to return to GSP for the summer of 2017. I acknowledge that I will only be excused from attending the retreat in the case of truly extenuating circumstances and that if I am aware of the existence of such circumstances (e.g. spending a semester abroad), I must notify Aris Cedeño immediately to discuss the possibility of my being excused.

I have read the above information and I agree to abide by the Governor’s Scholars Program’s stated
policies regarding the Spring Planning Retreat.

To return this form:

Please send this form as an email attachment
to Jenny Young ().
The subject of your e-mail should be “Reactivation Request.”
If you have questions, please contact:

Aris Cedeño

502-573-1618

The Reactivation Request deadline is as soon as possible, but no later than September 17th, 2016.