Northern California Collaboration for Low Incidence Personnel Preparation Application for NorCAL CLIPP Grant Program

Transcription

1 Northern California Collaboration for Low Incidence Personnel Preparation Application for NorCAL CLIPP Grant Program FIRST FUNDING SEMESTER: Please indicate the semester/year you would like to begin receiving financial support (e.g. Fall 2016) First Name Maiden/Middle Name Last Name Primary Street Address or PO Box City State Zip Primary Phone or Cell Last 4 Digits of SSN Student ID Primary (if different )Secondary Street Address or PO Box City State Zip (if different) Secondary Phone or Cell and Please provide address and contact information for a relative or other person which the program may contact on behalf of the scholar recipient, if necessary. Please do not submit the name of your spouse or person who resides with you. Name of next of kin/friend Secondary Street Address or PO Box City State Zip Address Phone 1. DEMOGRAPHIC INFORMATION Race/Ethnicity (check all that apply): American Indian or Alaskan Native Asian Black or African American (non Hispanic) Hispanic or Latino Native Hawaiian or Other Pacific Islander White (non Hispanic) Do you have a verifiable disability? yes (if yes, please attach appropriate documentation) no Age range: Under and over Degree(s) held upon entering the Mod/Severe Credential Program (Check all that apply): High School Diploma or equivalency Associate Degree (AA or AS) Bachelor s Degree (BA or BS) Master s Degree (MA, MS, or M.Ed.) Educational Specialist Doctoral Degree Post-Doctoral Degree State or Professional Credential/Certificate State-issued Endorsement Administration (General Education or Special Education 1

2 2. PROGRAM PRE-ENTRY STATUS: Were you employed during the academic year, prior to entry into this grant-supported training? yes no In what State were you working? (State abbreviation) Choose one type of employment that best describes the pre-entry position of this student. Special Education Teacher General Education Teacher (not special education) Early intervention, early childhood or preschool provider Special education paraprofessional/aide General education paraprofessional/aide (not special education) Early intervention, early childhood or preschool paraprofessional/aide Related or supportive services in early intervention, early childhood or in a school setting Related or support services in a non-school setting (e.g. adult services) Administrator/coordinator Higher education (e.g., faculty, research assistant, practicum coordinator Outside the field of education If employed in the field of education in your pre-entry position, what ages or grades of children did you provide direct or indirect services to? Early intervention (infants and toddlers) Early childhood (preschool, age 3-5, age 3-8) Birth through age 8 Elementary (grades K-6 th, grades K-8 th, PreK-6 th, PreK-8 th ) Middle/Jr. High School (grades 6 th -8 th, grades 7 th -9 th ) High School (grades 9 th -12 th, grades 10 th -12 th ) Junior/senior high combined Grades K-12th Birth through young adult (birth age 21, birth age out) Adolescents through post-secondary age/young adult Post-secondary age/young adult (18-22 years, years) Adults with disabilities All ages, birth through adulthood If you were employed in education, special education or related services, your credential status for the position was: Fully credentialed Less than fully credentialed 3. CURRENT EMPLOYMENT STATUS: Are you employed during this grant budget year? Yes No If yes, enter the average number of hours per week you are employed. (round to the nearest hour) Is this position Same position held before entry to this grant-support training? Different or new position? Choose one type of employment that best describes the position of this student. Special Education Teacher General Education Teacher (not special education) Early intervention, early childhood or preschool provider Special education paraprofessional/aide General education paraprofessional/aide (not special education) Early intervention, early childhood or preschool paraprofessional/aide 2

3 Related or supportive services in early intervention, early childhood or in a school setting Related or support services in a non-school setting (e.g. adult services) Administrator/coordinator Higher education (e.g., faculty, research assistant, practicum coordinator Outside the field of education If employed in the field of education, what ages or grades of children do you provide direct or indirect services to? Early intervention (infants and toddlers) Early childhood (preschool, age 3-5, age 3-8) Birth through age 8 Elementary (grades K-6 th, grades K-8 th, PreK-6 th, PreK-8 th ) Middle/Jr. High School (grades 6 th -8 th, grades 7 th -9 th ) High School (grades 9 th -12 th, grades 10 th -12 th ) Junior/senior high combined Grades K-12 th Birth through young adult (birth age 21, birth age out) Adolescents through post-secondary age/young adult Post-secondary age/young adult (18-22 years, years) Adults with disabilities All ages, birth through adulthood If you are employed in education, special education or related services, your credential status for the position was: Fully credentialed Less than fully credentialed EMPLOYMENT INFORMATION (IF EMPLOYED) School District or County Administrator Title District/Co. Street Address or PO Box City State Zip School Site Name Direct Supervisor School Phone School Street Address or PO Box City State Zip Average number of hours you work per week Grade levels you currently teach (check and circle all that apply): Primary grades K Elementary Middle 7 8 Secondary Post-Secondary If you are an intern: total number of pupils you serve If you are an intern: number of pupils you serve who have the following disabilities (note: Pupils may be counted in more than one category. Teachers of pupils with mild/moderate disabilities and emotional and behavioral disabilities are not qualified for financial support in this particular federal project.): Multiple handicapped Autistic Severe mental retardation Significant cognitive impairments Deafness and hard-of-hearing Visual impairment and blindness 3

4 Any impairment for which a small number of personnel with highly specialized skills and knowledge are needed to ensure the pupil a free appropriate education Other (specify) Requirements for Stipend Recipients: Document Access: Federal Register: June 5, 2006 (Volume 71, Number 107) Rules and Regulations Page From the Federal Register Online at DOCID: fr05jn06-11 Louis C. Danielson US Department of Education 400 Maryland Ave. SW Potomac Center Plaza, room 4160 Washington, DC Definitions: Secretary refers to the US Department of Education Scholar refers to intern or student Grantee refers to the CSU, Chico Education Specialist Programs Section refers to section 662(h)(1) of IDEA and 34 CFR part 304. Scholar must be admitted to and be enrolled in the CSU, Chico Moderate/Severe program or coursework. If the scholar is employed teaching pupils with low-incidence disabilities, the position must meet the following requirements. A majority (51% or more) of the persons to whom the scholar provides services for are individuals receiving special education, related services or early intervention; the scholar spends a majority (51% or more) of his or her time providing special education or related services to individuals with lowincidence disabilities as listed above. Scholar must be a Citizen or national of the US; or provides evidence from the US Department of Homeland Security that he/she is a lawful permanent resident of the United States; or in the United States for other than a temporary purpose with the intention of becoming a citizen or permanent resident. Candidate must show original documentation (see attached list of acceptable documents and verification form). Scholar must receive the training at the educational institution designated in the scholarship (CSU, Chico Education Specialist Program for M/S Disabilities) and make satisfactory progress in that Program. Satisfactory progress includes both field performance and coursework elements and is determined by this program. Scholars are individually evaluated by the university. No grade lower than a B- will be accepted in their course of study. Please refer to the Education Specialist Handbook for detailed information. Scholars must satisfactorily complete this program. If the scholar is pursuing coursework on a part-time basis, he/she will have a service obligation in this section based on the accumulated academic years of training for which the scholarship is received. Scholar must not accept payment of educational allowances from any other entity if that allowance conflicts with the candidate s obligation under this program. Stipend recipients must, after completing the Education Specialist M/S program, subsequently maintain employment in which the individual provides special education or related services to children with disabilities on a full-time or full-time equivalent basis and for a period of at least two years for every academic year for which assistance was received. The individual must be employed in a position in which a majority (51% or more) of the persons to whom the individual provides services are receiving special education, related services; the individual spends a majority (51% or more) of his or her time providing special education or related services to children with disabilities. Or if the position involves supervision (including in the capacity of a principal), teaching at the postsecondary level, research, policy, technical assistance, program development, or administration, the scholar spends at least a majority (51% or more) of his or her time performing work related 4

5 to the training for which a scholarship was received. A scholarship recipient must complete the service obligation within the period ending not more than the sum of the number of years required as stated above plus five additional years from the date the recipient completes the training for which the scholarship assistance was awarded. (Example: if a recipient received two (2) years of assistance, he/she must complete four (4) years of service within nine (9) years of program completion. If a recipient received 1 year of assistance, he/she must complete two (2) years of service within seven (7) years of program completion.) Up to $8, can be awarded to reimburse the scholar s expenses of fees, books, supplies, travel, and substitute teacher costs for release days involved in observations (paid directly by scholar). The program reserves the right to grant student stipends to support the individual s educational needs. Scholarship recipients agree to participate in evaluation studies related to this project, including follow-up surveys that assess project and graduate effectiveness. Recipients also give permission for data to be collected from their school sites during the Education Specialist program and for three years following their graduation. Upon successful completion of the this program in Moderate/Severe Disabilities, the grantee will provide the scholar with the following: A list containing all of the scholar s obligations. The number of years the scholar needs to work to satisfy the work requirements in Sec (d). The total amount of scholarship assistance received subject to Sec The time period, consistent with Sec (f) (1), during which the scholar must satisfy the work requirements. The scholar will then provide written certification that this list of obligations is correct. Scholars must provide the grantee all requested information necessary for the grantee to meet the exit certification requirements. Within 60 days after a scholar exits the program, and as necessary thereafter for any changes, the grantee will provide the Department, via US mail, all information that the Secretary needs to monitor the scholar s service obligation including social security number, address, employment setting, and employment status. Deferral or Exception to Performance or Repayment Based upon sufficient evidence to substantiate the grounds, the Secretary may grant an exception to the repayment requirement in Sec (j), in whole or part, if the scholar: Is unable to continue the course of study in sec or perform the service obligation because of permanent disability or Has died. Based upon sufficient evidence to substantiate the grounds, the Secretary may grant a deferral of the repayment requirement in Sec (j) during the time the scholar: Is engaged in a full-time course of study at an institution of higher education; Is serving on active duty as a member of the armed services of the United States; Is serving as a volunteer under the Peace Corps Act; or Is serving as a full-time volunteer under title I of the Domestic Volunteer Service Act of 1973 Repayment of Scholarship If not fulfilling the requirements in this section, subject to the provisions in Sec regarding an exception or deferral, scholar must repay any scholarship received, plus interest, in an amount proportional to the service obligation not completed as follows: The Secretary charges the scholar interest on the unpaid balance owed in accordance with the Debt Collection Act of 1982, as amended, 31 U.S.C Interest on the unpaid balance accrues from the date the scholar is determined to have entered repayment status. Any accrued interest is capitalized at the time the scholar s repayment schedule is established. No interest is charged for the period of time during which repayment has been deferred. Under the authority of the Dept Collection Act of 1982, as amended, the Secretary may impose reasonable collection costs. 5

6 A scholar enters repayment status on the first day of the first calendar month after the earliest of the following dates, as applicable: The date the scholar informs the grantee or the Secretary that the scholar does not plan to fulfill the service obligation under the agreement. Any date when the scholar s failure to begin or maintain employment makes it impossible for that individual to complete the service obligation with in the number of years required in Sec (f). Any date on which the scholar discontinues enrollment in the course of study under Sec (a). The scholar must make payments to the Secretary that cover principal, interest, and collection costs according to a schedule established by the Secretary. Any amount of the scholarship that has not been repaid pursuant to paragraphs (j) (1) through (j) (5) of this section will constitute a debt owed to the United States that may be collected by the Secretary in accordance with 34 CFR part 30. I attest, under penalty of perjury, that to the best of my knowledge, the above information I have provided is truthful and valid. Scholar Name Date If you wish to apply for this scholarship, please return to: Whitney Zeller Tehema 412 CSU, Chico Chico, CA Contact Information: wzeller@csuchico.edu Phone:

7 Name VERIFICATION FORM List A OR List B AND List C Documents that Establish Both Identity and Eligibility Documents that Establish Identity Documents that Establish Eligibility 1. U.S. Passport (unexpired or expired) 2. Certificate of U.S. Citizenship (INS Form N-560 or N-561) 3. Certificate of Naturalization (Form N-550 or N-570) 4. Unexpired foreign passport, with I-551 stamp or attached Form I-94 indicating unexpired employment authorization 5. Permanent Resident Card or Alien Registration Receipt Care with photograph (Form I-151 or I-551) 6. Unexpired Temporary Resident Card (Form I-688) 7. Unexpired Employment Authorization Card (Form I-668A) 8. Unexpired Reentry Permit (Form I-327) 1. Driver s license or ID card issued by a state or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color and address 2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color and address 3. School ID card with a photo 4. Voter s registration card 5. U. S. Military card or draft record 6. Military dependent s ID card 7 U.S. Coast Guard Merchant Mariner Card 1. U.S. social security card issued by the Social Security Administration (other than a card stating it is not valid for employment) 2. Certification of Birth Abroad issued by the Department of State (Form FS-545 or Form DS-1350) 3. Original or certified copy of a birth certificate issued by a state, county, municipal authority or outlying possession of the United States bearing an official seal 4. Native American tribal document 5. U.S. Citizen ID Card (Form I-197) 6. ID Card for use of Resident Citizen in the United Stated (Form I-179) 7.Unexpired employment authorization document issued by 9. Unexpired Refugee Travel 8. Native American tribal document DHS (other than those listed under Document (Form 1-571) 9. Driver s License issued by a List A) 10. Unexpired Employment Canadian government authority Authorization document issued by DHS that contains a photograph (Form I-688B) Document Verification: To be completed and signed by your employer or school secretary, program director or coordinator. Examine one document from List A OR examine one document from List B AND List C as listed above and record the title, number and expiration date, if any, of the document(s). List A OR List B AND List C Document Title: Issuing authority: Document #: Expiration date / / / / / / (if any) Document #: Expiration date / / / / / / (if any) I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named applicant, and that the document(s) appear to be genuine and to relate to the applicant named. Signature of Authorized Representative Print Name Title Business or Organization Name Address (Street name & number, City, State, Zip Code) Date 7