Personal Information
Leave this blank:
* Name:
* Address:
Street
City
State/Province
Afghanistan
Åland Islands
Albania
Algeria
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Andorra
Angola
Anguilla
Antarctica
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Chile
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Congo, Democratic Republic of
Cook Islands
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Korea, Republic of
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Libyan Arab Jamahiriya
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Nigeria
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Palestinian Territory, Occupied
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Poland
Portugal
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Romania
Russian Federation
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Saint Barthélemy
Saint Helena
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Samoa
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Saudi Arabia
Senegal
Serbia
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Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
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Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
United States
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
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United Kingdom
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Uruguay
Uzbekistan
Vanuatu
Vatican City State (Holy See)
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, US
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Postal Code/Other
* Phone (include country code):
-
* Mobile number:
-
Time Zone:
(UTC -12:00) Baker/Howland Island
(UTC -11:00) Samoa Time Zone, Niue
(UTC -10:00) Hawaii-Aleutian Standard Time, Cook Islands, Tahiti
(UTC -9:30) Marquesas Islands
(UTC -9:00) Alaska Standard Time, Gambier Islands
(UTC -8:00) Pacific Standard Time, Clipperton Island
(UTC -7:00) Mountain Standard Time
(UTC -6:00) Central Standard Time
(UTC -5:00) Eastern Standard Time, Western Caribbean Standard Time
(UTC -4:30) Venezuelan Standard Time
(UTC -4:00) Atlantic Standard Time, Eastern Caribbean Standard Time
(UTC -3:30) Newfoundland Standard Time
(UTC -3:00) Argentina, Brazil, French Guiana, Uruguay
(UTC -2:00) South Georgia/South Sandwich Islands
(UTC -1:00) Azores, Cape Verde Islands
(UTC) Greenwich Mean Time, Western European Time
(UTC +1:00) Central European Time, West Africa Time
(UTC +2:00) Central Africa Time, Eastern European Time, Kaliningrad Time
(UTC +3:00) Moscow Time, East Africa Time
(UTC +3:30) Iran Standard Time
(UTC +4:00) Azerbaijan Standard Time, Samara Time
(UTC +4:30) Afghanistan
(UTC +5:00) Pakistan Standard Time, Yekaterinburg Time
(UTC +5:30) Indian Standard Time, Sri Lanka Time
(UTC +5:45) Nepal Time
(UTC +6:00) Bangladesh Standard Time, Bhutan Time, Omsk Time
(UTC +6:30) Cocos Islands, Myanmar
(UTC +7:00) Krasnoyarsk Time, Cambodia, Laos, Thailand, Vietnam
(UTC +8:00) Australian Western Standard Time, Beijing Time, Irkutsk Time
(UTC +8:45) Australian Central Western Standard Time
(UTC +9:00) Japan Standard Time, Korea Standard Time, Yakutsk Time
(UTC +9:30) Australian Central Standard Time
(UTC +10:00) Australian Eastern Standard Time, Vladivostok Time
(UTC +10:30) Lord Howe Island
(UTC +11:00) Magadan Time, Solomon Islands, Vanuatu
(UTC +11:30) Norfolk Island
(UTC +12:00) Fiji, Gilbert Islands, Kamchatka Time, New Zealand Standard Time
(UTC +12:45) Chatham Islands Standard Time
(UTC +13:00) Phoenix Islands Time, Tonga
(UTC +14:00) Line Islands
* Email address:
Secondary Email address:
A Skype account is required for video conferencing, in case we need to do an interview via this format.
Please list your Skype account name:
(If you do not have a Skype account, this is a free downloadable program that can be found at www.skype.com )
Educational Background
* Are you currently attending school?
High School (Secondary/Upper School)
* School Name:
* City/State:
If so, what year?:
College/University
School Name:
City/State:
Degree:
Years Attended:
Major:
Graduate School
School Name:
City/State:
Degree:
Years Attended:
Major:
Business, Vocational or other
School Name:
City/State:
Degree:
Years Attended:
Major:
Other Information
* Profession:
(Please select)
Teacher
Director
Therapist
Parent of Special Needs Child
Medical Professional
Other
* Current Employer:
* Supervisor's Name:
Employer's Address:
Street
City
State/Province
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of
Cook Islands
Costa Rica
Cˆte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao, People's Democratic Republic of
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Phillippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
United States
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City State (Holy See)
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, US
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Postal Code/Other
* Employer's Phone:
* Employer's Email:
* Languages Spoken:
* Nationality:
Length of interest for Teacher Exchange:
How did you hear about the Teacher Exchange Program?
(please select)
Internet Search
Word of Mouth
Conference
Other
* With what types of children do you primarily work? (Check all that apply)
* What is the age range of the children that you serve?
References
Please list the names of three references. References must have a working phone number or email address.
* Name:
* Organization:
* City/Country:
Website: (leave blank only if there is no website)
* Phone:
-
Email:
* Relationship:
* Years Known:
* Name:
* Organization:
City/Country:
Website:
Phone:
-
Email:
Relationship:
Years Known:
* Name:
* Organization:
City/Country:
Website:
Phone:
-
Email:
Relationship:
Years Known:
* Explain what kind of influence you currently have on your local community that will allow you to effectively implement trainings to others upon returning home:
* Briefly explain why you are interested in the Heartspring Teacher Exchange Program:
Questionnaire
*
1. What is your primary role?
*
2. What type of services do you provide in your current role? (Please check all that apply)
*
3. How do the children you work with primarily communicate? (Please check all that apply)
*
4. Do the children you serve have behavioral difficulties?
If yes , how frequently do you work with children who have behavioral difficulties?
If yes , which of the following have been used to address the behavior difficulties?
Has this plan/intervention been successful?
5. Do the children you serve have the help and support necessary to be successful in their home and community?
If no , what is the main concern?
The next section is to help us identify appropriate trainings for you. Your answers will not affect whether you are selected, it's simply to help us know where to focus trainings.
* 6. Tell us briefly what you believe is the cause of autism:
* 7. Are there any known cures for autism?
* 8. What are evidenced-based interventions? (please give examples)
* 9. Identify the main principles of Applied Behavioral Analysis (ABA):
* 10. What are the main concerns in your country regarding children with special needs? In what areas do people in your country need to be educated or trained?
* 11. Please indicate in what areas you would like additional training (if selected, this will be used to schedule your training time while here):
Communication
Training / Professional Development in Special Education
Interactive Classroom or Residential Training
Training / Professional Development in Management, Administration and Operation
Other
* In addition to the trainings checked above, all participants will tour other local organizations that serve people with disabilities.
* 12. Personality Inventory: This area is not a basis for acceptance, rather it will help us give you the most positive experience possible and will help us to match you with professionals in the best manner possible.
Please check the words that most describe you:
Please tell us a little more about yourself:
Please provide any other information that will allow us to best suit your needs during your visit: