| Student Name : |
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First Name : |
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Middle Name : |
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Last Name : |
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Email Address: |
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Mailing Address: |
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| Daytime Phone Number: ex: ###-###-#### |
include dashes |
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Name of School District where currently employed |
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1.
Are you a special educator currently teaching in
a special education classroom with a valid
provisional license in emotional disturbance,
learning disabilities, mental retardation and/or special education/general?
Yes
No
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a.
If yes, which area are you endorsed in,:
emotional disturbance, learning
disabilities, mental retardation and/or special education/general?
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b.
If yes, when does your provisional
license expire? Example June 30, 2010
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c. If you are not currently teaching with a
provisional license, please explain why you
are seeking course work in special
education.
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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
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3.
Are you currently enrolled in the VCU Masters of
Education or Teaching Program?
Yes
No
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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
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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.
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6.
Are you able to attend an orientation via telephone conference? You will need to have access to a phone and Internet connection at the same time.
Yes
No
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7.
Are you familiar with using "Blackboard", an
online classroom?
Yes
No
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8.
Additional Comments
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