Verification of current tuberculosis clearance and current CPR.

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1 CSU, Chico School of Education Application Packet for the Education Specialist Internship Program for Mild/Moderate or Moderate/Severe Disabilities Name: Credential Application Packets may be hand delivered to the Education Specialist Intern Office, Tehama 403, or the School of Education Office, Tehama 101 OR mail to: Education Specialist Programs, ATTN: Denise Dion CSU, Chico Chico, CA Please include this checklist with your application. The following items are required for completion of your application. Use this application checklist form to help organize your materials. We suggest you keep a copy of all documents submitted. 1. Provide Transcripts Submit two official sets of transcripts from all colleges and universities previously attended. Submit two unofficial sets of CSU, Chico transcripts. 2. Complete Credential Application Requirements Completed Credential Program Application (attached). (Accurate information is essential to the procession of your application.) One copy of your professional résumé. Handwritten Belief Statement form (attached). Handwritten Experience Statement form (attached). Two original letters of recommendation that attest to the attributes you possess that will contribute to effective teaching. Letters should be current and on letterhead. You have met the Certificate Of Clearance requirement if you hold a valid California Teaching Credential or Substitute Teaching Permit. If you have not met this requirement: Apply for a Certificate of Clearance (fingerprint check). Obtain the Clearance packet at this link: or in the SOE office. Complete Steps 1 and 2. Include a copy of the completed Request for Live Scan sheet with your credential application. Clearance by the CA Commission on Teacher Credentialing is required by state law for your school placement (student/supervised teaching). You have met the Subject Matter Competence requirement if you hold a valid California Multiple Subject Teaching Credential or a valid California Single Subject Teaching Credential in art, English, music, mathematics including foundational level, foreign language, science including science, social science If you have not met this requirement, please provide verification of California Subject Matter Competency in one of the following areas: CSET - Multiple Subject Subject Matter preparation verification form in one of the following areas - art, English, music, mathematics including foundational level, foreign language, science including science, social science. OR CSET - art, English, music, mathematics including foundational level, foreign language, science including foundational general science or specialized science, social science. Information regarding the CSET exam can be found at Photocopy of CSET scores. If you have completed a Single Subject program with a focus on teaching English music, mathematics including foundational level, foreign language, science including science, social science, you do not have to complete the CSET exam. Photocopy of subject specific SMC waiver form. Subject Matter Advisor will forward SMC waiver forms directly to the School of Education, ATTN: Denise Dion. Basic Education Skills Requirement. Proof of CBEST or CSET Writing Skills Exam or CSU Placement Test (ELM & EPT) or Early Assessment Program (EAP English & Math) or Basic Skills exam from another state See program advisor for passing criteria requirements needed. Verification of current tuberculosis clearance and current CPR. Important Message To enter our internship program, you must complete the application, successfully complete an interview, complete the pre-service requirements and be employed (under a contract) in a Mild/Moderate or Moderate/Severe teaching position in our service area. We will allow a minimum of a.5 position. You can complete the application, interview, and pre-service requirements without being employed, but you cannot begin the internship program until you are employed (this is a state requirement). CSU, Chico Education Specialist Internship Program s service area includes the following Counties: Butte Colusa Glenn Lassen Modoc Plumas Shasta Siskiyou Sutter Tehama Trinity Yuba Pre-Service Requirement You have met the Pre-Service Requirement if you hold a valid California Teaching Credential and one of the following: English Learner Authorization CLAD Certificate CTEL Certificate If you do not hold a valid California Teaching Credential with CLAD, CTEL or English Learner Authorization, please provide verification of: Completion of 40 hours of English Learner (EL) Authorization. May include EL Authorization, CLAD, or CTEL coursework or modules. Completion of 120 hours of credential coursework, classroom experience, or modules. Contact the Educ. Spec. Internship Advisor (ddion@csuchico.edu) for more information on completing the Pre-Service Requirement.

2 EDUCATION SPECIALIST INTERNSHIP CREDENTIALING PROGRAM PRELIMINARY MILD/MODERATE AND/OR MODERATE/SEVERE SPECIALIZATIONS CREDENTIAL PROGRAM APPLICATION School of Education (SOE) This form is used by SOE to certify that pre-qualifying requirements are met for the Education Specialist Internship Credentialing Program. Please fill out the form completely if you wish to be considered for this program. LAST NAME FIRST NAME STUDENT ID # LAST 4 DIGITS OF SS # Letters of Recommendation Two original letters of recommendation that attest to the attributes you possess that will contribute to effective teaching. One letter should be from a principal who has observed your work in a classroom setting. The second letter may be from a professor, teacher, supervisor, school administrator who can verify your professional abilities. Letters should no older than 6 months, and on letterhead. Subject Matter Competence CSET Credential(s) Held: Copy of CSET-MS pass status (if required) MUST PASS ALL SUB-TESTS The internship program can only accept the following Single Subject preparation areas: art, English, music, mathematics including foundational level, foreign language, science including foundational general science or specialized science, social science. Copy of CSET-Single Subject pass status or Single Subject Competency waiver form from Single Subject Advisor. MUST PASS ALL SUB-TESTS Basic Skills Tests (CBEST) CBEST exam taken, individual score sheet enclosed CSET-MS exam including the CSET Writing Skills Exam Other Exam pass status: Other Basic Skills exam from another state (specify ELM/EPT/EAP) Certificate of Clearance (fingerprinting): Credential(s) held: Substitute Teaching Permit held Certificate of Clearance online application submitted on (date) Bachelors Degree Institution: Major: Graduation date or anticipated date:

3 If you do not hold a California Teaching Credential, please provide verification of U.S. Constitution requirement. (Example: CSU, Chico POLS 155; Butte Community College POS 2) University Course Number Term Completed Grade Colleges/Universities attended (list all) CSU, Chico Unofficial transcript enclosed Employment (complete only if employed as a special education teacher) School District or County Administrator Title District/Co. Street Address or PO Box City State Zip School Site Name Direct Supervisor School Phone School Street Address or PO Box City State Zip Native English Speaker: yes no Ethnicity: American Indian or Alaska Native Asian Black or African American Hispanic/Latino of any race Native Hawaiian or Other Pacific Islander White Decline to State Used for demographic reporting purposes only I certify that the above and any other information submitted by me in conjunction with my application is accurate and complete. Applicant s Signature Date PO Box or Street Address City State Zip Code Phone PLEASE NOTE: To enter our internship program, you must complete the application, successfully complete an interview, complete the pre-service requirements and be employed (under a contract) in a Mild/Moderate or Moderate/Severe teaching position in our service area. We will allow a minimum of a.5 position. You can complete the application, interview, and pre-service requirements without being employed, but you cannot begin the internship program until you are employed (this is a state requirement).

4 California State University, Chico Professional Studies In Education Credential Programs STATEMENT OF PROFESSIONAL GOALS AND AUTOBIOGRAPHICAL BACKGROUND LAST NAME FIRST NAME Part 1: Belief Statement: The mission of the School of Education includes the following: We believe in the power of education to create a diverse, democratic, socially responsible society in which every student is valued. Based upon the teaching philosophy that you have developed, describe specific teaching practices that would work towards meeting the goals of the mission statement. Use the space provided below. Note: This form will not be kept confidential. It will be read by university faculty and possibly by public school personnel.

5 Part 2: Experience Statement: Provide a handwritten description of an experience from your life and discuss how that experience would influence your work with diverse populations of children (struggling learners, English Learners, children from low socioeconomic backgrounds, or children with disabilities or exceptional needs). Include specific examples and use the space provided below. Note: This form will not be kept confidential. It will be read by university faculty and possibly by public school personnel. SIGNATURE: DATE: