Applicants to Alternative Certification Practicum ONLY

School Information

School district

School: ___

School
School address

Principal: ___

Principal

Telephone: _____

School population
Telephone

School population: _____

Gender and Ethnicity (number of students)

# Females: ___ # Males: ___

# Females: ___
# Males: ___
White: ___ Black/African American: ___ American Indian/Alaska Native: ___
Asian: ___ Hispanic/Latino Origin: ___ Native Hawaiian/Other Pacific Islander: ___
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: ___
Multiracial: ___ Students who qualify for free or reduced meals: ___
Multiracial: ___ Students who qualify for free or reduced meals: ___
504 Plans: ___ IEPs/IFSPs: ___ GSSPs: ___ ELL: ___ Behavior Plans: ___
Multiracial: ___ Students who qualify for free or reduced meals: ___

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

Multiracial: ___ Students who qualify for free or reduced meals: ___
Multiracial: ___ Students who qualify for free or reduced meals: ___
Multiracial: ___ Students who qualify for free or reduced meals: ___
Multiracial: ___ Students who qualify for free or reduced meals: ___
504 Plans: ___ IEPs/IFSPs: ___ GSSPs: ___ ELL: ___ Behavior Plans: ___

Classroom Information

Grade(s): ___ Class enrollment: ___

Class enrollment:
Grade(s):

Content area(s): ___

Content area(s):

Gender and Ethnicity (number of students)

# Females: ___ # Males: ___

# Females: _____
# Males: _____
White: ___ Black/African American: ___ American Indian/Alaska Native: ___
Asian: ___ Hispanic/Latino Origin: ___ Native Hawaiian/Other Pacific Islander: ___
# Males: _____

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

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

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

Multiracial: ___ Students who qualify for free or reduced meals: ___
Multiracial: ___ Students who qualify for free or reduced meals: ___
504 Plans: ___ IEPs/IFSPs: ___ GSSPs: ___ ELL: ___ Behavior Plans: ___
Multiracial: ___ Students who qualify for free or reduced meals: ___
Multiracial: ___ Students who qualify for free or reduced meals: ___

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: ___

Applicant’s signature:
Date

Principal's statement:

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:

Principal's signature:

Date:

Revised Spring 2018