CCF Berlin Summer Program 2019 Application

* required information
 
How did you learn about this opportunity?:*
I have attended Tools for Tolerance for Educators programs at the MOT:*
Yes
No
Explain further, if you wish:
I have taken my students to the MOT:*
Yes
No
Explain further, if you wish:
First Name:*
Last Name:*
Address Line 1:*
Address Line 2:
City:*
State:*
ZIP/Postal Code:*
Phone:*
Email:*
Birth Date:*
(mm/dd/yyyy)
Passport Number:*
Current School Name:*
Current Supervisor Name:*
Current Supervisor Title:*
Current Supervisor Phone:*
Current Supervisor Email:*
School Address (Please include the city, state, and zip code):*
School Telephone #:*
What subject(s) and/or grades do you currently teach?:*
How long have you been teaching?:*
Please list college/university attended, degree and date degree was earned (lowest to highest degree):*
Have you covered the Holocaust in lessons before?:*
Yes
No
If so, approximately how many classroom hours do/did you spend on the topic?:*
Were there particular challenges or issues you faced in teaching the subject?:*
Describe the community in which you teach (socio-economic, ethnic, size):*
Do you have any special dietary or religious needs?:*
In brief, please describe your motivation for participating in this program:*
Have you been to Europe before, and if so, when? What countries did you visit?:*
Do you have any impediments to participating fully in an emotionally and physically challenging program?:*
Yes
No
PLEASE NOTE: The program can be emotionally and physically challenging and involves a lot of walking.:
If yes, please explain:*
Please provide us with a contact person in the event of a medical emergency during your visit:*
Relationship to emergency contact:*
Emergency Contact Phone Number:*
Emergency Contact Email Address:*
Submit Resume:*
Click here to attach file
Simon Wiesenthal Center Updates:
Yes
No
        

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