COVE

Application form - Deadline for SPRING 2008 is JANUARY 11, 2008!

Contact carole boyle with application questions....caboyle@vcu.edu

Please fill out your Name in Full!

Student Name :  
First Name :
Middle Name :
Last Name :
Email Address:
Mailing Address:
Daytime Phone Number: ex: ###-###-#### include dashes
Name of School District where currently employed

Street:

 

City:

 

Zip Code:

 

Telephone:

  ex: ###-###-#### include dashes

May a representative of VCU contact your employer to verify your employment?
 Yes
 No

1. Are you a special educator currently teaching in a special education classroom with a valid conditional license in emotional disturbance, learning disabilities and or mental retardation?  Yes  No
 

a. If yes, which area are you endorsed in,: emotional disturbance, learning disabilities, and/or mental retardation?


b. If yes, when does your conditional license expire? Example June 30, 2007
c. If you are not currently teaching with a conditional license, please explain why you are seeking course work in special education.
 
2. Please select the Superintendent's Region where you are currently teaching
 1 2 3 4 5 6 7 8
 Please check here if you do not know the Superintendent's Region
 
3. Are you currently enrolled in the VCU Masters of Education or Teaching Program?
 Yes  No
 
4. Are you currently enrolled in a Master’s of Education Program at any other university?
Yes    No

If yes, please provide the name of the university
 
5. Have you taken any course towards licensure at VCU or any other university? Yes    No

a. If yes, list each course you have taken towards licensure.

Name of University Course Title Course Number Course Description (Course description must be quoted directly from the universities course listing) Date Completed

6. Are you able to attend a locally held, face-to-face, orientation meeting? 

Yes    No

7. Are you familiar with using "Blackboard", an online classroom?
Yes    No
 
8. Additional Comments


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