Teacher Name:

Teacher Email:

Teacher Phone: xxx-xxx-xxxx

Where are your classes located? Please provide the address.

Program Name:

Program Manager/Director Name:

Program Manager/Director Email:

Program Manager/Director Phone: xxx-xxx-xxxx

Please change the next question to read: Does your program have ABE and ESL classes in session between June 22 and August 21?
Yes No

Will you be able to attend “Match Day” on Friday, May 8th from 6PM to 9PM?
Yes No

PART 2: Classroom Information

Please indicate the type and level of class for which you are requesting a fellow:
Select ESL ABE GED

What is your average daily attendance during the summer?

Please describe the demographics of your classroom. Please include age ranges, races, ethnicities, primary languages, etc. Please use 500 characters (approximately 100 words) or less:

Please list the days and times of the class you mentioned for which you are requesting a fellow. If you are unsure of your summer schedule, please provide your best guess:

PART 3: Fellowship Vision
Please answer the following questions in 1000 characters (approximately 150 words) or less:

Describe how you have incorporated health literacy into your classroom. If you have not, please discuss how you would like to do so.

What qualities are you looking for in a health literacy fellow?

Medical students are not adult educators. How will you help your fellow improve his/her teaching and communication skills?

How is the fellowship related to your professional goals as an adult educator?

Please describe your preliminary idea(s) for using "We Are New York" in your classroom to teach health literacy. What are some activities your lessons will include? How do you envision the fellow contributing his/her health content knowledge?

PART 4: Schedule
Please list days that your program is closed and/or that you are not teaching class. Please also provide dates of intake, testing, professional development, etc. If you are unsure of your schedule, please provide your best guess.

June

July

August

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