School district:

School: ___

School address: ___

Principal: ___

Telephone: _____

School population: _____

Gender and Ethnicity (number of students)

# Females: ___ # Males: ___

White: ___ Black/African American: ___ American Indian/Alaska Native: ___

Asian: ___ Hispanic/Latino Origin: ___ Native Hawaiian/Other Pacific Islander: ___

Multiracial: ___ Students who qualify for free or reduced meals: ___

504 Plans: ___ IEPs/IFSPs: ___ GSSPs: ___ ELL: ___ Behavior Plans: ___

Grade(s): ___ Class enrollment: ___

Content area(s): ___

Gender and Ethnicity (number of students)

# Females: ___ # Males: ___

White: ___ Black/African American: ___ American Indian/Alaska Native: ___

Asian: ___ Hispanic/Latino Origin: ___ Native Hawaiian/Other Pacific Islander: ___

Multiracial: ___ Students who qualify for free or reduced meals: ___

504 Plans: ___ IEPs/IFSPs: ___ GSSPs: ___ ELL: ___ Behavior Plans: ___

Alternative Certification Applicant's statement: I verify that the information in this application is current and accurate. I further verify that I am employed full-time as a Special Education Teacher at this site.

Applicant's signature: ___

Date: ___

I verify that this applicant is employed full-time as a Special Education Teacher at this site and that he or she has my permission and support to complete his or her alternative certification practicum here, during the next academic semester (fall or spring).

Principal's signature:

Date:

Revised Spring 2018