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1. Full Name

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2. Primary Phone Contact

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3. Primary Email Contact

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4. At what school do you currently teach?

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5. What subjects are you certified to teach?

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6. What subject(s) and grade(s) will you (most likely) be teaching in the 2013-2014 school year?

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7. What grades and subjects have you previously taught?

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8. How long have you been employed at your current school?

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9. How long have you worked in the field of education? What positions have you held besides classroom instructor, if any?

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10. Please rate your INTEREST in incorporating the following into your classroom:

  A lot Some None
Web (blogging, social media, web design, etc.)
Graphics (image manipulation, image creation)
Video (storyboarding, video production and editing, distribution)
Audio (audio production and editing, podcasting, beatmaking)

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11. Please list the technology that you have available for use in your classroom, school, and district. Ex: computer labs, laptops, digital cameras, document projectors, etc.

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12. What do you believe is the purpose of education today? What do you believe SHOULD be the purpose of education today? Please answer both questions.

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13. How can media and technology be used to support your students' critical thinking, creativity and collaboration?

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14. Please share a sample lesson plan that illustrates your answer to the question above (this could be a lesson that you have taught, or would like to teach in the future).

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15. Describe any experiences you have had with community-organizing or youth development outside of the school setting, currently or in the past. Please list specific years and locations of the work.

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16. What practices have you found to be the most effective at building relationships of trust, mutual respect and transformation with youth?

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17. How did you hear about the Detroit Future Schools program?

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18. Will you be able to attend AMP Camp, the mandatory DFS network retreat in August, 2013? The retreat lasts five days total, with three nights spent off-site at a retreat facility.

To read more about AMP Camp, please follow this link: http://alliedmedia.org/#!/news/2012/10/12/amp-camp-2012-education-more-just-creative-and-collaborative-world

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19. Is there anything else you would like to tell us?

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