Application Form

Tertiary Fees Funding Support: Literacy

Primary and Intermediate Teachers 2017

Please fill out ALL sections of this form

School Information

(1) Name of School: ……………………………………….…..…(2)ID Number:….….…...

(3) Postal address: …………………………………………….………….....……………………………

……………………………………………...... …

(4) Phone: …………………..…………(5) Email:……..………………………………………

(6) Yearsthe school has been involved in Literacy Professional Development: …………

Teacher Information

(7) Teacher’s name: …………………………………………(8) Email: ……………….………

(9) Likely class level in 2017: …………………………………….

(10) Are you currently teaching students who are struggling in reading? Yes No

(11) Are you currently teaching students who are struggling in writing? Yes No

(12) Yearsyou have been involved in LiteracyProfessional Development: ………………

(13) Circle the number of years you have been teaching:

1 – 2 years3 – 5 years6 – 10 years11 – 20 years 20 + years

(14) Is this paper part of a Middle Schooling Qualification?YesNo

(15) Are you planning to study the paper below as part of a group? YesNo

(16) Names of other teachers in this study group: ……………………………………….….

………………………………………………………………………………………….……….

  • Teachers who are studying together need to complete their own application form. All the forms should be sent to the Ministry of Education in the same envelope.
  • Teachers who are recipients of Ministry of Education study awards are not eligible for the subsidy. Once the study award is completed recipients will be eligible for the subsidy.

Tertiary Study Information

(17) Code number of tertiary paper:……………… Semester: 1, 2, whole year, summer

(18) Title of tertiary paper: ………………………………………………….……..…

(19) Name of University: …………………………………………….…….…………

Declaration

In making this application, we certify that the information given is true and accurate, and that we have no objections to the use of this information for the purpose of this application.

We understand that if this applicationis successful, the teacher listed above will enroll and completethe university literacy paper listed. If the teacher believes that they have issues successfully completing the paper, we understand that the teacher will immediately contact the Ministry of Education to discuss their options.

We understand thatif this applicationis successful, half of the tuition feewill be paid to the school by the Ministry of Education, with the other half paid for by the Board of Trustees, who has approved the necessary expenditure. We understand the Ministry of Education contribution will be sent to the Board in full upon receipt of confirmation of acceptance into the paper listed and confirmation of the tuition fee.

We understand that the school may need to pay the full tuition fee before the Ministry of Education’s contribution has arrived at the school.

We agree to support the teacherand may allow some of the teacher’s CRT, classroom release time, to be used for study purposes. We understand that norelease time or leave provision is part of this scheme.

We understand thatif this applicationis successful, the teacher will send a copy of the results (grade achieved), to the Ministry of Education upon completion of the paper. The Ministry of Education reserves the right to invoice the school for the Ministry’s contribution if the results are not received. Feedback and comments about the scheme would also be welcome.

We agree to participate in any evaluation of the scheme.

We accept that the decision of the selection panel is final.

Signature of Teacher: …………………………………………….…… Date: …………….

Name of Principal: ……………………………………….…………….

Signature of Principal: ……………………………………………….... Date: …………….

Name of BOT Chairperson: ……………………………….…….……

Signature of BOT Chairperson: ……………………………….……... Date: …………….

The school should retain a copy then scan and email the application form to: with subject line “TFFS- surname”.

Or post to

Attn:

Tertiary Fees Funding Support (Level 5)

Ministry of Education

PO Box 1666

WELLINGTON 6140