Application for CLAD through CTEL

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1 Application for CLAD through CTEL Contact: Education Credential Programs Phone: (951) or (951) University of California, Riverside Extension Education Credentials Office 1200 University Avenue Riverside, CA 92507

2 Welcome! Thank you for your interest in UCR Extension s CLAD through CTEL program. In this document you will find the application form and a checklist to assist you in completing your application packet. The application fee of $50.00 can only be submitted by debit/credit card, please do not send cash or check. Please contact Student Services at (951) and refer to Certificate Fee-XCA- CLAD-CTEL Application Fee to make this payment. In an effort to ensure your application is complete when received, we recommend when ordering your university transcripts to have them mailed to yourself, do not open them and submit them sealed with the application as one packet. We are committed to the highest possible level of customer service, and will review your application, once it is complete, within 10 business days 1. At that time a decision letter will be mailed to your home address. At any time during this process you are welcome to contact us with any questions or to check on the status of your application. We look forward to working with you! 1 Please note that submission of a completed application does not imply automatic acceptance into the program.

3 Applicants must possess: ADMISSION REQUIREMENTS 1. A bachelor s degree from an accredited institution with a cumulative minimum grade point average of 3.0 (based on a four-point scale). For applicants that hold a graduate degree, graduate GPA will also be considered. If the overall computed GPA is below the stated 3.0 minimum, an applicant may be asked to submit a letter of explanation, which will be considered in making the admissions decision. 2. Any one of the following valid credentials issued in the State of California: Multiple Subjects Single Subject Education Specialist Level I or II Education Specialist Preliminary or Clear Speech-Language Pathology or Clinical or Rehabilitative Services with a Special Class Authorization School Nurse Services Credential with Special Teaching Authorization in Health Visiting Faculty Permit Children s Center Permit (excluding emergency) Child Development Permit ( excluding Assistant or Associate Permits) APPLICATION CHECKLIST A complete application packet includes all of the following: 1. Completed application form 2. Non-Refundable Application fee - $50 (Please call Student Services (951) or and refer to Certificate Fee-XCA-CLAD-CTEL Application Fee when paying ) DO NOT SEND CASH OR CHECK 3. Official, Sealed Transcripts of all college coursework 4. Copy of CA credential, if you do not currently hold a CA credential please submit the Non-California Teaching Credential Disclaimer form 5. Copy of out-of-state credentials 6. Official, Sealed CTEL test scores if applying for the blended program Please return as one packet to: UCR Extension c/o Education Credentials Office 1200 University Ave. Riverside, CA

4 Credentials Office Use Only Date application fee paid Order number Verified by: Appropriate valid CA Credential Date verified Verified by: Approved Not approved: Needs further review Approved by Director of Ed. Not approved by Director of Ed. Date Received: * Required Information APPLICATION FORM CLAD through CTEL University of California, Riverside Extension *Name: (First) (Middle) (Last) Previous or maiden name: *Date of Birth *Social Security Number: * address you check on a daily basis: Home address: Number and Street City Zip Code ( ) Area Code Phone Number Mailing address if different from home address: Please send all mailed correspondence to this address Number and Street City Zip Code

5 Employer Information: School/Site Name: Supervisor/Principal Name: School District & County Professional Experience: (Chronologically, current assignment first) District School Assignment Dates of Employment Supervisor District School Assignment Dates of Employment Supervisor District School Assignment Dates of Employment Supervisor Personal Information: Ethnicity- Please circle one (Responses are kept confidential and used for program quality purposes only): C= American Indian or Alaskan Native A= Black/African American E= Mexican/Mexican American/Chicano L= Latino/Other Spanish F= Caucasian/White/Non- B= Japanese/ Japanese American American Hispanic D= Chinese/ Chinese American M= Pacific Islander Y= Other Asian K= Filipino/Filipino American G= Decline to state X= Korean/ Korean American R= East Indian/ Pakistani D= Other

6 Academic Background: College Major/Minor Degree & Date College Major/Minor Degree & Date College Major/Minor Degree & Date I verify that all of the information above is true and correct Signature of Applicant Date Thank you!

7 Non-California Teaching Credential Disclaimer I,, understand that the California (Legal First and Last Names) Commission on Teacher Credentialing (CTC) and UCR Extension require that candidates for the CLAD Through CTEL certificate program hold a valid California teaching credential at the time of applying for candidacy into the program. At this time I do not hold a California teaching credential. I hold a teaching credential from valid until. (Name of State Held Credential) I am currently in the process of applying for my California Teaching Credential. I am fully aware that if the CTC denies my California teaching credential, I am responsible of all expenses incurred at UCR Extension such as but not limited to tuition, books and fees. I further understand that I will not be eligible to participate in the program, nor to be recommended for any authorization from the CTC. With this Disclaimer on file, I plan to pursue the EL Authorization at UC Riverside Extension. I also understand that I am responsible for notifying the Credentials Office when my California teaching credential has been granted. At that time I understand my application will be reviewed to be formally accepted; only then will I be eligible to obtain the EL Authorization pending the successful completion of all required coursework. Signed: Date:

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