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E-School Course Proposal Form
Please copy and paste into a word processor or print this page. Or submit your proposal online.
Name ________________________________________
School _______________________________________
Social Security Number __________________________
Address ______________________________________
Home Address _________________________________
City/State/Zip __________________________________
City/State/Zip __________________________________
School Phone __________________________________
Home Phone __________________________________
Fax __________________________________________
email address___________________________________
Principal ______________________________________
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Grade Levels Taught:
Subjects Taught:
Degrees:
Professional Experiences:
Professional Activities:
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Course Title & ACCN number:
Instructors:
Course Objectives:
Target Audience:
Statement of Need:
Proposed Method of Delivery:
Prerequisites:
State Performance Standards:
Course Description:
Lesson Outline:
Assessment Methods of Student Performance:
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Signature of Applicant
Signature of Principal

Date
Date

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