Principals’ Summer Institute
June 7-12, 2020
Please type or print legibly.
Full Name (for Certificate) ______________________________________________
Title/Position _____________________________________________
(Current Year 2019-20)
Title/Position _____________________________________________
(Changes only for Upcoming Year 2020-21)
Year began current position_____________ School____________________________
School Address ___________________________ City _________________________
State_______ Zip Code ____________ District _______________________________
School Phone __________________School E-mail_____________________________
Cell Phone_________________ Personal E-mail ______________________________
Years as administrator ______________ Years as a Principal__________________
Choose only one option:
30 SEMI Credits? 3 OSL Credits? William Carey Univ. Course Credit
Required to attend: MS License Certificate #_______________
Check Enclosed/Mailed Purchase Order Attached/Emailed
(Registration fee does not include lodging)
Preferred Name (Name Tag): ______________________________
Polo-shirt (
short sleeve-Men’s cut only) sizes: circle S M L XL 2XL 3XL 4XL 5XL
In case of emergency, please contact:
1) Name _______________________________Relationship_____________________
Home Phone ________________ Cell _________________Work _____________
2) Name_________________________________Relationship____________________
Home Phone ________________ Cell _________________Work_________________
Medical information in case of an emergency (medications, conditions, food allergies)
_____________________________________________________________________
_____________________________________________________________________
Space&is&limited!&
Priority&is&given&to &
early&registration&&
!
$1,200.00&R egular&&
Registration&Fee&
(after!3/15/20)!
DOES&NOT&INCLUDE&LODGING!
!
EARLY&REGISTRATION&
ONLY&$1000.00&an d&M UST&
be&received&befo re&&
March&15,&2020.&(Groups&of&
3&or&more&from&one&district&may&
register&early&for&$900&per&
person.)&
!
All&Registration&will&be&confirmed&
electronically&after&receiving&a&
completed&2-page&registration&form&
and&check&or&purchase&order&form&
from&your&school&district.&Forms&
may&be&emailed&to&
martice@millsaps.edu&
!
Make checks payable to:
MILLSAPS COLLEGE
PRINCIPALS’ SUMMER INSTITUTE
Email Registration form and purchase
order form to martice@millsaps.edu.
Checks!must!be!received!by!
MAY&15,&2020&
!
Cancellation&Policy&
Full&refund&if&cancelled&BEFORE&
April&5,&2020.&&Cancellations&after&
April&5&and&before&May&10,&2020&at&
only&50%&refund.&&All&cancellations&
after&May&10,&2020&require&full&
payment&with&no&refund.&
Registration!Forms!can!be!
downloaded!at!the!Principals’!
Institute!
Website:&
http://principalsinstitute.millsaps.edu!!
!
Mail&Checks&to:&
Millsaps'College'Principals’'Institute
&
'Box&150082/1701&N.&&State&
Street'
Jackson,&MS&39210-0001&
601-974-1354!or!601-331-1744!
Fax:!601-974-1397!
Cindy!Martin,!Director!
E-mail:!martice@millsaps.edu!
PARTICIPANT PROFILE INFORMATION
Please answer the following questions. Limit your answers to one paragraph per question.
1
) Describe your school’s mission, priorities, and/or goals for the next school year.
2) What will be your role in achieving the priorities and goals mentioned above?
3) What current challenges does your school face?
4) What do you expect to gain as a result of your participation in the Millsaps
College Principals’ Summer Institute? Be specific.
5) List the “Role Alike” group that most closely fits your job assignment for the
upcoming year. (Example: principals, assistant principals, elementary, middle,
secondary)
________________________________________________________________
6) Awards, Recognitions, or Honors your school has received while in your leadership
position: ________________________________________________________
________________________________________________________________
Participant’s Signature ____________________________________
Date _______________
*Note: You are not fully registered until Millsaps PSI receives
a Purchase Order or Check from your school district.
ABOUT YOUR SCHOOL
School’s Name:
_________________________
_____________________
Level
o Elementary
o Middle/Jr. High
o K-12
o High School
o Other _____________
Community
o Rural
o Suburban
o Urban
Type
o Public
o Private
o Parochial
Number of
_______Students
_______Teachers
_______Specialists
Avg. Student’s Family Income
o High ($60,000)
o
Medium ($30,000-60,000)
o Low (-$30,000)
Ethnic Mix %
____Asian
____Caucasian
____Hispanic
____African American
_____Native American
_____Other
School Rating 2018-19(circle):
A B C D F
DISTRICT INFORMATION
Superintendent:
_________________________
Superintendent Phone Number and
Email:
____________________________
_______________________
Person in charge of Federal
Programs:
Name:_____________________
Phone Number
:
_________________________
Email:______________________
____________________________
_______________________
click to sign
signature
click to edit
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