Consortium Application The Virginia Consortium for Teacher Preparation in Early Childhood Special Education (ECSE) Application for Participation Part I Demographic Information NameDate Date of Birth: MonthDayYear Address CityStateZip Phone Email Name of place of employment: Name of your principal/supervisor: Principal/Supervisor phone number: Work Address Work Phone Number: Fax Number: Part II Position and Experience Which of the following item(s) best describes you? (please check all that apply): I am employed I am not employed. I recently graduated from a college or university, with a major in . I am a VPI teacher who needs to get licensed in special education-ECSE. I am an ECSE teacher, working on a provisional license. I am a SE teacher working on the elementary or secondary level, but interested in attaining an endorsement in ECSE. I am a general education teacher who is interested in attaining a license and endorsement in ECSE. I am a related service provider in . I am an administrator. My title is . I have taken an introductory course in special education. I am hoping that this program will allow me to enter a master’s degree. I have taken online courses at other colleges or universities. I am currently in a master’s degree program at another university. It is most likely that I will have a teaching contract during the 2012-2013 school year. Part III Teaching License Status, if applicable Please check all of the following items that describe you: I am licensed to teach in another state(s) in the areas of . I have a permanent teaching license in general education (elementary and/or secondary levels), but I’m not teaching. My GE teaching endorsement(s) is in . I have a permanent teaching license in special education, but I’m not teaching. My SE endorsement(s) is in I hold a provisional teaching license in special education, but I’m not teaching. My provisional license is in . My provisional license will expire on (month/year): . I hold a provisional license in special education, and I am teaching. My provisional license is in . My provisional license will expire on (month/year): . (If provisionally licensed) I have had a transcript review done by my school district, and/or VDOE, and have been told which courses I will need in order to get a permanent license. The approximate date of the transcript review was . According to my VDOE transcript review, I will need the following courses for license and ECSE endorsement: (Please check all of the courses that you will need to take.) Intro/Survey to Special Education Child Growth and Development Foundations of Education Characteristics of Developmental Disabilities Speech-Language Development Behavior management Assessment (in ECSE) Instructional Programming Speech/language Development Medical Aspects Family-Centered Intervention Consultation (collaboration) Other Note: If you are not currently employed by a school division, please indicate your primary reason for seeking enrollment in this ECSE Consortium: Part IV Application Status Please check any or all that apply: I have been admitted to Lynchburg College as a: Certificate student (allows you take 4-6 ECSE courses) Non-degree seeking student (allows you to take 2 ECSE courses) Master’s degree student I am in the process of gaining admittance to Lynchburg College Part V Educational History My university education has included the following: Degree Subject University Year My grade point average for graduate course work, thus far, is (if applicable): I am planning to take the following course/s through this ECSE Consortium: (mark all that apply) Medical Aspects Instructional Programming ECSE Assessment in ECSE Family Centered Interventions Behavior management in ECSE Speech and language development Please note that personnel connected with this Consortium are not in a position to verify which courses a student needs for licensure/endorsement. Students are encouraged to work with their school district’s licensure specialists and/or VDOE to ascertain which courses they need. Acceptance into the Consortium is dependent upon admittance to Lynchburg College.