Every question in this Program Application is appropriate.  Please answer each one in the space provided.  If more space is needed, please add an additional sheet.  If you have questions regarding this Program Application, please contact Harry or Trudy Monti at SpecialEdMagic@aol.com.

     Please mail completed applications and reference information to:  Harry Monti, 803 Sherwick Terrace, Manchester, Missouri  63021.

THIS PROGRAM APPLICATION IS SOLELY FOR THE USE OF THE SOCIETY OF AMERICAN MAGICIANS AND ALL INFORMATION CONTAINED HEREIN WILL REMAIN STRICTLY CONFIDENTIAL.

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THIS APPLICATION SHOULD BE COMPLETED BY THE EDUCATOR, INSTRUCTOR, OR LEADER WHO WILL BE TEACHING OR LEADING THE MAGIC FOR SPECIAL EDUCATION PROGRAM.

Please print or type information.

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School / Facility Wishing to Implement Program

1.    School/Facility Name:

2.    Street Address:

3.    City/State/Zip:

4.    # Participants Anticipated in Program:                Phone #:

5.    Name of School Principal or Head of Facility:

Note:  Please attach to this Application a letter from the School Principal or head of the special facility authorizing use of this program in the classroom and recommending the below-named educator as instructor of the program.

Educator / Instructor / Leader Teaching Program

6.    Name:

7.    Street Address:

8.    City/State/Zip:

9.    Office Phone #:                              Home Phone #:

10.   Place and Date of Birth:

11.   Marital Status:              Spouse's Name if Applicable:

12.   Prior Addresses, if any, for last 5 years and length of time at each address:

Employment / Educational Background

13.   Length of time employed at above educational facility:

14.   If employed by anyone else in the last 5 years, give employer's name, address and length of employment:

15.   Educational Background (list degrees, names, locations and dates of colleges or universities you attended):

16.   Have you worked as a leader in other groups with special disabilities:  Please list and explain responsibilities:

Driving Background

17.   Driver's License State and #:

18.   Have you ever been denied a license to operate a motor vehicle or has your driver's license been suspended or revoked within the last 10 years?  If yes, please explain why.

19.   As a motor vehicle operator, have you ever been in an accident involving fatalities, no matter when, or involving personal injury in the last 5 years?  If yes, please list and explain.

20.   Have you ever been arrested or received a ticket for driving under the influence of alcohol or drugs, drunk driving, reckless driving or careless driving, no matter when?  If yes, explain.

Personal Background

21.   Do you have any health limitations or health considerations that would limit your role as an instructor of the mentally challenged?  If yes, explain.

22.   Have you used any illegal drugs, or been treated or hospitalized for drug abuse in the last 10 years?  If yes, explain.

23.   Have you ever used alcohol excessively, or been treated or hospitalized for the use of alcohol in the last 10 years?  If yes, explain.

24.   Have you ever been charged, arrested or convicted of any of the following?  If yes, please explain.

            The possession, transfer or use of alcohol?

            The possession, transfer or use of illegal drugs?

            Crimes in which the alleged victim or accomplice was a minor?

            Activities in which you allegedly physically or sexually abused anyone, male or female, or allegedly condoned the abuse by others?

            Activities in which you allegedly were involved in the creation, possession, use or transfer of illegal drugs?

25.   Has any adverse action been taken by any youth organization, school, church or day care center against you while you were an employee or volunteer for such organization of entity?  If yes, explain.

26.   To the best of your knowledge and belief, are there any facts or circumstances involving you or in your background that would call into question your being entrusted with the supervision, guidance, and care of young people or individuals with disabilities?  If yes, explain.

References

27.   List three people who have known you for at least 5 years.

a.         Name:

Connection:

Street Address:

City/State/Zip:

Phone #:

b.         Name:

Connection:

Street Address:

City/State/Zip:

Phone #:

c.         Name:

Connection:

Street Address:

City/State/Zip:

Phone #:

     I understand that the information that I have provided may be verified and that the individuals and organizations named herein may be contacted in connection with such verification.  Further, I recognize and understand that other persons and organizations who may be in a position to provide information in response to any inquiry arising out of this profile/application may be contacted.

     I release, hold harmless, and agree to indemnify the Society of American Magicians, its National Council, its assemblies, officers, employees, agents, volunteers, and the S.A.M. Magic Endowment Fund from any and all liability to me in connection with their good faith used on behalf of the program using magic as a teaching tool for the mentally challenged and any information provided as a result of, or in connection with the Program Application, and I similarly release, hold harmless, and agree to indemnify such organizations and individuals from any and all liability to me in connection with their good faith efforts to gather information about me as a result of, or in connection with this Program Application.

    I promise that in my participation in this program using magic as a teaching tool for the mentally challenged, I will bear true allegiance to the Society of American Magicians, its Constitution and By-Laws, and the laws of my city, state (province) and nation.

     By signing this Program Application, I certify that the information provided herein is true, complete and accurate.  I promise to immediately notify the Special Assemblies Chair or the National Administrator of the Society of American Magicians of any changes in the information supplied above.

Signature:_______________________________            Date:______________

*  *  *  *  For Office Use Only  *  *  *  *

This Program Application has been reviewed and approved by:

            Special Assemblies Chair:

            S.A.M. National President:

            Magic Endowment Fund Chair: