Academy Name: *
Choose your academy... Academy not listed Achieve Charter Academy Arbor Academy Black River Public School Byron Center Charter School Canton Preparatory High School Chandler Woods Charter Academy Cornerstone-Jefferson Douglass Academy Covenant High School Grand Rapids Covenant Schools Detroit Crossroads Charter Academy Detroit Achievement Academy Detroit Enterprise Academy Detroit Merit Charter Academy Detroit Premier Academy Eagles Nest Academy East Arbor Charter Academy Endeavor Charter Academy Excel Charter Academy Flint Cultural Center Academy Fostering Leadership Academy GEE Compass Academy Gerald Dawkins Academy Global Heights Academy Grand River Academy Grand River Preparatory High School Hanley International Academy Hillsdale Preparatory School Kalamazoo Covenant Academy Knapp Charter Academy Legacy Charter Academy Light of the World Academy Lincoln-King Adams-Young Academy Madison-Carver Academy Martin Luther King Jr. Education Center Academy Metro Charter Academy Michigan Mathematics and Science Academy Muskegon Covenant Academy New Paradigm College Prep New Paradigm Glazer-Loving Academy Oakland Academy Old Mission Peninsula School PSAD Paragon Charter Academy PrepNet Virtual Academy Reach Charter Academy Saginaw Covenant Academy South Canton Scholars Charter Academy Taylor Preparatory High School The Greenspire School Timberland Charter Academy Vanderbilt Charter Academy Vanguard Charter Academy Walker Charter Academy Warrendale Charter Academy Washington-Parks Academy West Michigan Academy of Arts and Academics West Michigan Aviation Academy Westfield Charter Academy William C. Abney Academy Windemere Park Charter Academy

Your Name:

Title:

First: *

Middle:

Last: *

Suffix:

Address:

Street: *

City: *

State: *
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Zipcode: *

Home Phone Number: *

Work Phone Number: *

Fax Number:

E-mail Address: *

Employer: *

Position/Job Title: *

Are you the parent/guardian of a current or former student at the academy you are applying to for board membership? *
Yes No

(Please indicate all of the following that apply: High School including City, State and Graduation month and year; Undergraduate institutions including the type of degree such as B.A., B.S., etc., Graduation month and year, and Major/Minor; and Postgraduate and Professional institutions again including the type of degree such as J.D., M.A., M.S., M.B.A., Ph.D., etc., Graduation month and year, and the area of concentration)

High School

High School: *

City/State: *

Graduation Date (Month/Year): *

Undergraduate Institutions (B.A.; B.S.; B.B.A.; etc.)

Institution 1: *
Choose Degree Type... B.A. B.S. B.B.A. B.F.A. Other Not Applicable

Degree Type: *

Institution 2:
Choose Degree Type... B.A. B.S. B.B.A. B.F.A. Other Not Applicable

Degree Type:

Institution 3:
Choose Degree Type... B.A. B.S. B.B.A. B.F.A. Other Not Applicable

Degree Type:

Post-Graduate and Professional Institutions (M.A.; M.S.; M.B.A.; M.Ed.; Ph.D., J.D., M.D., etc.)

Institution 1:
Choose Degree Type... M.A. M.S. M.B.A M.Ed. Ph.D. J.D. M.D. Other Not Applicable

Degree Type:

Institution 2: Choose Degree Type... M.A. M.S. M.B.A M.Ed. Ph.D. J.D. M.D. Other Not Applicable

Degree Type:

Institution 3:
Choose Degree Type... M.A. M.S. M.B.A M.Ed. Ph.D. J.D. M.D. Other Not Applicable

Degree Type:

Are there any changes from your last application that may influence your appointment?
If you selected yes, LIST ANY CHANGES FROM YOUR LAST APPLICATION THAT MAY INFLUENCE YOUR APPOINTMENT (Specifically list all changes to your Education History, Ages of your Children, Conflict of Interest and Ethical Matters *
Yes
No

Please Explain:

I recognize that all information submitted with this application or gathered by Grand Valley State University as a result of this application becomes a matter of public record, subject by law to disclosure upon request to members of the general public. I will hold Grand Valley State University, its trustees, officers, employees or authorized agents harmless from liability for the disclosure of any information it reasonably believes is true based upon my representations or resulting from this application process.

By checking this box I agree to the above terms and certify that the information provided in this statement is, to the best of my knowledge, true and accurate.

Please Note: Public School Academy Board Applications are subject to public disclosure under the Michigan Freedom of Information Act.

A criminal records check must be conducted as a condition for appointment as a public official serving on the board of a public school academy authorized by Grand Valley State University. This consent does not authorize nor will Grand Valley State University conduct a consumer credit check.

Information requested on this page will be used to conduct a criminal records check and will not be used to determine qualifications as a proposed public school academy board member. This page will be removed prior to review of the information contained in the application.

Additional Information Needed for Background Check

Date Of Birth: *
Month: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year: 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024

Maiden Names:

Any Previously Used Names?

Most Recent Former Address:

Street: *

City: *

State: *
- Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming

Zipcode: *

Gender: *
Male Female

Ethnicity: *
Caucasian
African American
Hispanic
Asian
Native American
Other

By checking this box I agree to the above terms and assert and certify that the information provided is, to the best of my knowledge, true and complete.