MAGIC FOR
SPECIAL EDUCATION
PROGRAM APPLICATION

The Society of American Magicians is committed to establishing a nationwide program using magic as a teaching tool for special education classes. If you would like to introduce this program into your classroom or facility as a "teaching tool" for those with special disabilities, or would like to establish an independent class, the Society requests that you complete this Program Application so your request may be considered. The Society of American Magicians at all times promotes the high ideals and ethics of the Society and endeavors to insure a safe environment for all participants in this unique program.

Every question on this Program Application is appropriate. Please answer each one in the space provided. If more space is needed, please attach an additional sheet. If you have questions regarding this Program Application, please contact:

Society of American Magicians,
Magic for Special Education Chair
803 Sherwick Terrace
Manchester, MO 63021
636-394-4191
Magic4SpecialEd@MontiMagic.com
www.magicsam.com

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

School / Facility Incorporating 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:______________________________________________________

6. Email address for Principle:___________________________________________________________________

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.

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Educator/Instructor/Leader Teaching Program


7. Name:_________________________________ Social Security #:_________________________________

8. Street Address:_________________________________________________________________________

9. City:___________________________________________ State:________________ Zip:______________

10. Email Address:________________________________________________________________________

11. Office Phone #:______________________________ Home Phone #:______________________________

12. Place of Birth:___________________________________________ Date of Birth:___________________

13. Marital Status:______________ Spouse's Name if Applicable:___________________________________

14. Prior Addresses, if any, for last 5 years & length of time at each address:___________________________

______________________________________________________________________________________

Employment / Educational Background


15. Length of Time Employed at Above Educational Facility:______________________________________________

16. If employed by anyone else in the last 5 years, give employer's name,

address and length of employment:________________________________________________________________

17. Educational Background (list degrees, names, locations and dates of colleges

or universities you attended):_____________________________________________________________________

18. Have you worked as a leader in other groups with special disabilities?

Please list and explain responsibilities:_____________________________________________________________

____________________________________________________________________________________________

Driving Background


19. Driver's License State and #:__________________________________________________________________

20. 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._____________________________

___________________________________________________________________________________________

21. 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. _______________________________

__________________________________________________________________________________________

22. 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


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

____________________________________________________________________________________________

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

____________________________________________________________________________________________

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

____________________________________________________________________________________________

26. 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?

27. 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.________________________________

____________________________________________________________________________________________

28. 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

29.List three people who have known you for at least 5 years:
a.


Name:___________________________Connection:__________________________

Street Address:_______________________________________________________

City, State and Zip:_____________________________________________________

Phone #:_____________________________________________________________

b.


Name:___________________________Connection:__________________________

Street Address:_______________________________________________________

City, State and Zip:_____________________________________________________

Phone #:_____________________________________________________________

c.


Name:___________________________Connection:__________________________

Street Address:_______________________________________________________

City, State and 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 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 President__________________________________________