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					                                     School of Education Application Packet
                                for the Rural Teacher Residency (RTR) Program
Deadlines for Application:
    Credential Applications are due on the first of each month October through January for          Verification of Fingerprints: submit 2
    early application consideration. 2nd round applications are due by January 20.                 copies of one of the following:
Submit application to Tehama 401, by 4:00 p.m. of application due date.
Please include this checklist with your application                                                   Certificate of Clearance
The following items are required for                                                                  Valid or expired Emergency Permit
completion of your application. Use this       2. Complete Application Requirements                   Valid or expired Substitute Teaching
application checklist form to help                                                                     Permit
organize your materials. We suggest you        $50 credential program application fee               Valid or expired California multiple
keep a copy of all documents submitted.        made payable to CSU, Chico.                             or single subject or education
                                                                                                       specialist teaching credential
The application process begins with the        Completed Credential Program                      Clearance packets are available online at:
completion of the application and the          Application (attached). (Complete and accurate      http://www.csuchico.edu/soe/
submission of all required documents.          information is essential to the procession of       credential-services/ or www.ctc.ca.gov
The application and documentation can          your application.)
be mailed to:                                                                                      One copy of official transcripts
                                               Three copies of your professional résumé.         from each college/university attended. In
Cheri Taylor                                   For assistance you may contact the Career           addition, CSU, Chico students must also
Rural Teacher Residency Program                Planning and Placement Office (898-5253,            provide an unofficial or portal transcript.
California State University, Chico             Student Service Center 270).
Chico, CA 95929-0465                                                                               Provide a copy of CBEST scores
                                               Handwritten Statement of Belief form              for verification. (Multiple Subject
  OR                                                                                               Program applicants who have passed
                                               (attached).
Deliver to Cheri Taylor, Office of                                                                 CSET for Multiple Subjects may waive
Outreach, Research, & Grants, Tehama           Handwritten Experience Statement form             CBEST by passing the CSET Writing
Hall Room 401.                                 (attached).                                         Skills Exam.)

Once your file is complete, the program        *Candidate Disposition Form (attached)            Verification of tuberculosis
adviser will review your application. If       should be given to the teacher in whose             clearance [TB](must be current) and
your documentation meets minimum               classroom your early school experience was          CPR.
requirements an interview will be              done. The teacher should complete the form
scheduled. To expedite this process,           and mail it to Cheri Taylor; RTR Program;           *Early Field Experience.
please send all necessary documentation        CSU, Chico; Chico, CA 95929-0465. You               Verification of completion of your 45
with the application. This application is      must fill in the top portion before giving it to    hours of early classroom experience
valid for 6 months.                            the teacher.                                        verified by a credentialed teacher.

Please note that the entire application will   Two original letters of recommendation            California Subject Matter
be reviewed by the interview panel.            that attest to the attributes you possess that      Competency (SMC)
Please put some thought into your              will contribute to effective teaching. One letter   If you are pursuing a Multiple Subject
responses. Thank you for your interest in      should be from a credentialed teacher who has       credential program, passage of the CSET
our program.                                   observed your work in a classroom setting.          Multiple Subject Examination is required
                                               This may be the teacher with whom you               prior to application deadline (March 1)
1. Complete an application for                 completed your 45 hours of early field              for priority consideration.
admittance to CSU, Chico                       experience. The second letter may be from a         Photocopy of CSET scores.
                                               work supervisor or a professor who can verify
    Apply online at: www.csumentor.edu         your professional abilities. Letters should be      If you are pursuing a Single Subject or
                                               current and on letterhead.                          Education Specialist credential,
payable to CSU, Chico in the amount of                                                             appropriate subject matter verification is
$55 or the Graduate School Fee Waiver.         Three (3) Additional References. Provide          required prior to application (March 1)
Visit                                          the names and phone numbers of three people         for priority consideration.
http://www.csuchico.edu/graduatestudies/       who know you in an educational setting              Photocopy of CSET scores or SMC
prospective/admissions_forms                   (college professor, teacher, school                 waiver form. Subject Matter Advisors
                                               administrator, church school director, or work      will forward SMC waiver forms directly
                                               supervisor).                                        to Tehama 401.
from all colleges or universities                                                                  *If you have not completed an early field
previously attended. If you are, or expect                                                         experience, please contact Cheri Taylor at
to be, a graduate of CSU, Chico, you do                                                            ctaylor@csuchico.edu or 530-898-6887 as soon
not need to submit transcripts to the                                                              as possible for advisement.

August 2011
Graduate School.
              the process for the MA in
Education for the RTR program.
See instructions at:
www.csuchico.edu/soe/advanced/
education/rtr




August 2011
                                                                      CSU, CHICO SCHOOL OF EDUCATION
                           Rural Teacher Residency (RTR) Program Ap plication
RTR is an 18-month program leading to a credential and a master’s degree in education, for candidates who are interested in working in high-need
rural schools. Coursework, including online, campus-based and field-based modes, begins in the spring semester and summer session prior to a full-
time academic year residency in a rural school. During the school year, teacher residents will continue their coursework, engage in intensive daily
collaboration with their assigned Mentor Teachers, participate as members of professional learning communities at their school sites, and engage in
site-based inquiry leading to completion of a master’s thesis or project.

Last Name:                                             First Name:                             Student ID #:                                   Social Security #:

Check appropriate box:  Multiple Subject                                                                                     Single Subject - Subject area:
                        Education Specialist (Level I Mild/Moderate)                                                         Education Specialist (Level I Moderate/Severe)

Residency Placement Preference (Please number 1- 4 in order of 1st, 2nd, 3rd and 4th choice):
               Cascade Union Elementary SD                             Marysville Joint Unified SD                             Orland Elementary SD                 Palermo Union SD
Subject Matter Competence
CSET (Multiple or Single Subject)                                                              Program Waiver (Single Subject Only)
   Exam taken, individual scoresheet enclosed                              In progress, progress reviewed on_____________________________
   Exam to be taken or retaken on __________________________               Signed waiver enclosed or sent to School of Education
Basic Skills Tests (CBEST)
   CBEST exam taken, individual scoresheet enclosed (Multiple Subject Program applicants who have passed CSET for Multiple Subjects may waive CBEST by
     passing the CSET Writing Skills Exam)
   Exam to be taken or retaken on ________________________________  Other (specify ELM/EPT/EAP):
Certificate of Clearance (fingerprinting):  Certificate of Clearance online application submitted on _______________________________ (date)
   Fingerprinting completed on ________________ (following LiveScan, online application must be submitted)  Credential(s) Held:
Bachelor’s Degree       Institution:
                        Major                                                          Graduation date or anticipated date
Colleges/Universities attended (list all)
   CSU, Chico                                                                                                              Unofficial transcript enclosed
                                                                                                                            Official transcript enclosed
                                                                                                                            Official transcript enclosed
Prerequisite Courses Completed (Equivalent courses must be approved by the department)
      CSU, Chico            Title of Course                                           Multiple        Single          Education            Semester   Institution              Equivalent
      Course                                                                          Subject         Subject         Specialist           / Grade                             Course #
                                                                                                                                           Received
     POLS 155              American Government
     CMST 131              Speech Communication Fundamentals
     HCSV 450/451          Health Ed.  Elem  Secondary
     EDTE 302              Access & Equity in Education
     EDTE 580              Educational Psychology                                    NA                              NA
     ENGL 471              2nd Language Acquisition
     PSYC 355              Child/Adolescent Psychology (MS)                                          NA              * Option 1
     PSYC 414              Psychology of Teaching (MS)                                               NA              * Option 2


                            Foreign Language (1 yr high school or 3 units of
                            university credit)
     SPED 343              Overview of Special Education                             NA              NA
     SPED 564              Management of Learning Environments                       NA              NA
     SPED 580              Introduction to Autism Spectrum Disorders                 NA              NA
                            Intro to Democratic Perspectives in K-12 Teaching
      EDTE 255
                            (45 hr requirement)
     OR
                            OR
      SPED 569
                            **Field Exp. in Inclusive Settings
      EDTE 520              Fundamentals of Teaching Practice
     OR                    OR
      SPED 561              **Curriculum & Instruction in Inclusive Settings
*Education Specialist candidates choose either PSYC 355 or PSYC 414             **prerequisite for Education Specialist candidates only.


I certify that the above and any other information submitted by me in conjunction with my application is accurate and complete.
Applicant Signature:                                                                                                                                       Date:
Local Mailing Address:


Phone:                                                                                                                         Email:
August 2011
                                  California State University, Chico
                             Co-STARS Rural Teacher Residency Program

_____________________________________________________ _____________________________________________________
Last Name                                              First Name

Part 1: Belief Statement




August 2011
                                              California State University, Chico
                                         Co-STARS Rural Teacher Residency Program

_____________________________________________________ _____________________________________________________
Last Name                                                                      First Name

Part 2: Experience Statement




Note: This form will not be kept confidential. It will be read by university faculty and public school personnel.

_____________________________________________________                                 _____________________________
Signature                                                                             Date
August 2011
California State University, Chico
School of Education
Chico, California 95929-0465__________________________________________________________________________
530-898-6887
                                             CANDIDATE DISPOSITION FORM
Candidate Name: ___________________________________                                 Multiple Subject  Single Subject
                                                                                    Education Specialist Mild/Moderate
                                                                                    Education Specialist Moderate/Severe
Candidate Program Level:                  Early School Experience          Teaching   Practicum I         Teaching Practicum II
To the respondent: Effective credential candidates should enter our programs with certain dispositions and continue to develop those
dispositions through the experiences provided in our professional programs. Please mark an “x” in the box that represents your rating
of the dispositions, keeping in mind the candidate’s current program level. For explanations of each performance level and disposition,
please see the rubric on the back of this form to guide you in your ratings. The purpose of this form is to guide and inform program
faculty in their acceptance decisions and to monitor professional growth throughout the credential program.

                                   Disposition                                 Needs           Developing           Acceptable
                                                                            Improvement

     Disposition #1
     Appreciates and values human diversity, recognizes community
     and cultural norms, shows respect for students’ varied talents and
     perspectives, seeks to foster culturally-appropriate
     communications and demonstrates best practices in his or her
     field.

     Disposition #2
     Believes that all children can learn, appreciates their varying
     abilities and persists in helping all children achieve success.

     Disposition #3
     Committed to continuous, self-directed learning, critical thinking
     and reflection in order to refine instructional practice and deepen
     knowledge in the academic disciplines.

     Disposition #4
     Demonstrates pride in the education profession and participates
     in collaborative relationships with colleagues, students, parents,
     and social and professional communities and agencies.

     Disposition #5
     Committed to the expression and use of democratic values and is
     committed to creating a learning environment that fosters active
     engagement in learning and encourages positive social
     interaction.

Signature ______________________________________ Print Name ___________________________________

Position _________________________________________________ Date _______________________________

School ___________________________________________________ Phone _____________________________

Total hours spent in your classroom: _____       Dates from_________ to _________ Diverse classroom  yes         no

Number of English Language Learners in your classroom:

Recommend for Credential Program acceptance:                    yes no     (Early Field Experience only)
Additional comments are welcome.
August 2011
                                                              Needs Improvement                                       Developing                                       Acceptable
               Disposition #1
Appreciates and values human diversity,            Unfairly interacts and responds to               Is aware of the need to interact and respond     Interacts and responds with all students fairly;
recognizes community and cultural norms,           students; is unaware of opportunities to         with all students fairly; responds to            looks for opportunities to enhance cross-
shows respect for students’ varied talents and                                                      opportunities to enhance cross-cultural          cultural understandings; invites and integrates
                                                   enhance cross-cultural understandings; is
perspectives, seeks to foster culturally-                                                           understandings; recognizes individual            students’ individual differences into the
appropriate communications and                     non-responsive to students’ individual
                                                                                                    differences; attempts to encourage cultural      classroom environment; encourages cultural
demonstrates best practices in his or her field.   differences; misses opportunities to             sensitivities and perspectives; is aware of      sensitivity and perspectives; models culturally
                                                   encourage cultural sensitivities and             culturally responsive pedagogical practices      responsive pedagogical practices
                                                   perspectives; is unaware of culturally
                                                   responsive pedagogical practices
               Disposition #2
Believes that all children can learn,              Not engaging with students at all levels of      Recognizes and engages all levels of student     Looks for and inquires about a variety of
appreciates their varying abilities and persists   student abilities: Easily frustrated when        abilities: Tries to help students that don’t     strategies to engage all levels of student
in helping all children achieve success.           students don’t understand; focuses on higher     understand; attempts to interact all levels of   abilities: Persists with students to try to help
                                                   level students only; isn’t aware of students     student abilities; seeks to help all students    them understand; encourages students at all
                                                   who need help                                                                                     levels; seeks strategies to be more effective
                                                                                                                                                     with all students.
               Disposition #3
Committed to continuous, self-directed             Rarely asks questions about classroom            Asks some questions about classroom              Often asks questions about and comments on
learning, critical thinking and reflection in      dynamics; passes by opportunities to discuss     dynamics; occasionally engages in thinking       classroom dynamics; shows a real interest in
order to refine instructional practice and         teaching practice; demonstrates inadequate       about and discussing teaching practice;          thinking about and discussing teaching
deepen knowledge in the academic                   knowledge of subject and curriculum, and/or      demonstrates knowledge of subject and            practice by initiating discussions often;
disciplines.                                       has few ideas to increase his/her knowledge      curriculum, but is less certain of ways to       demonstrates superior knowledge of subject
                                                                                                    increase his/her knowledge                       and curriculum; describes realistic and specific
                                                                                                                                                     workable plans for increasing his/her
                                                                                                                                                     knowledge.
               Disposition #4
Demonstrates pride in the education                Dresses inappropriately and/or exhibits          Dresses and conducts self appropriately;         Models professional dress and conduct; uses
profession and participates in collaborative       inappropriate and/or unprofessional behavior;    communicates effectively with students and       verbal communication that enhances
relationships with colleagues, students,           uses verbal communication that does not          colleagues; meets scheduled time/hour            interactions with students and colleagues;
parents, and social and professional               foster interaction; Attendance, punctuality,     commitment and is prepared                       meets or exceeds scheduled time/hour
communities and agencies.                          and/or preparation is problematic                                                                 commitments, arrives promptly and is well
                                                                                                                                                     prepared
               Disposition #5
Committed to the expression and use of             Unaware of the need for interdependent,          Aware of the need for interdependent,            Recognizes and values interdependent,
democratic values and is committed to              collaborative social interaction; unresponsive   collaborative social interaction; listens to     collaborative social interaction; values student
creating a learning environment that fosters       to student ideas; displays little interest or    student ideas; actively observes group work;     ideas; facilitates student group work, when
active engagement in learning and                  involvement in group work; limited               responsive to students                           asked; very responsive and respectful to all
encourages positive social interaction.            responsiveness to students                                                                        students, both verbally and nonverbally




August 2011

				
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