CI ELO application form School of Speech Language and

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CI ELO application form School of Speech Language and Powered By Docstoc
                  APPLICATION FOR A PROJECT                       CI²ELO TRAINEESHIP

Name:                                                      E-mail:
Address:                                                   Red ID#:
City/Zip:                                                  Social Security #:
Phone(s):                                                             (required by US government)

Program Information
___ Speech-Language Pathology: M.A. degree and California Credential in Clinical-Rehabilitative Services
       ___ Incoming 1 Year Graduate Student
       ___ Incoming 2 Year Graduate Student (currently 1st Year)
___ School Psychology: Ed.S. degree and California Credential in School Psychology
       ___ Incoming 1st Year Graduate Student
       ___ Incoming 2 Year Graduate Student (currently 1st Year)
       ___ Incoming 3 Year Graduate Student (currently 2nd Year) for ___ One Year or ___ Two Years

            ORGANIZE YOUR APPLICATION IN A FILE FOLDER (labeled with CI²ELO & your name)
                                And include the following items.

___ This form including your Language Learning Profile, Essays, and signed Affidavit & Service Obligation
___ A copy of your current transcript. If you are new to SDSU, please submit a copy of your transcript from the
    university that awarded your bachelor's degree (unofficial copy is fine) – highlight courses particularly
    relevant to CI²ELO.
___ Your vita (or résumé) – highlight experiences particularly relevant to CI²ELO

                                          SEND or DELIVER to:
 Speech Language Students                           School Psychology Students
 Vera Gutierrez-Clellen, Ph.D.                      Katina M. Lambros, Ph.D.
 School of Speech, Language & Hearing Sciences      Department of Counseling & School Psychology
 (SLHS 240)                                         (NE 194)
 College of Health & Human Services                 College of Education
 San Diego State University                         San Diego State University
 5500 Campanile Dr.                                 5500 Campanile Dr.
 San Diego, CA 92182-1518                           San Diego, CA 92182-1179

                      Important: Make a copy of this application for your own files/portfolio.
Your Language Learning Profile
Please conduct a self-assessment of your proficiencies in a language other than English; then describe how you
learned this language. If you have proficiency in more than one language other than English, please copy and

Language (specify)
              NONE, OR TOO
PROFICIENCY   MENTION        LIMITED-1           LIMITED-2             FLUENT-1            FLUENT-2                PRO-1                    PRO-2

COMP.                        basic - of          basic - when adults   understand          understand parents      understand               understand technical &
                             children's          speak slowly          adults talking at   when talking about      professional speech of   professional presentations
                             communication                             normal rate         school or children      others (e.g., IEP)
                             basic               basic conversation    fluent              parent interview, IEP   professional             presentations before
                             conversation with   with adults, fluent   conversation        participation and       exchanges and            professional audiences
                             children            with children         with adults         translating             technical conversation

                             basic brief notes   personal letters      official letters    professional letters    psychological reports,   professional papers and
                             & messages                                to parents          and inquiries of        IEP goals                journal articles

                             basic brief notes   personal letters,     formal letters,     novels professional     college level texts in   professional journals,
                             & messages          magazines             magazines           solicitations           psychology or            technical graduate/
                                                                                                                   education                professional texts

What percent of your time do you use this language: at home _____%                                      in the community _____%

List and briefly describe all of the ways by which you learned this language (e.g., first language; courses in high
school &/or college; formal immersion programs).
ESSAY #1: Knowledge & Experience with Other Languages or Culture(s). Describe the depth and breadth of
your knowledge base in and experiences with languages (plural) and cultures (plural) beyond English and
“Mainstream”-American; include experiences with English-learners. Double-spaced; 1-2 pages in length.
ESSAY #2: Multilingual Challenges in the Schools. Describe the three greatest challenges that school
personnel encounter in multilingual schools. Use your knowledge base and/or experiences to suggest ways to meet
those challenges. Double-spaced; 1-2 pages in length.
ESSAY #3: CI²ELO Responsibilities. If selected as a Project CI²ELO trainee, you will be responsible for your own
learning and for the learning of your fellow trainees. What does that mean to you? What would you expect from
your fellow trainees? How would you ensure that you are attaining necessary learning outcomes? Double-spaced;
1-2 pages in length.
                                     PROJECT CI²ELO: TRAINEE AFFIDAVIT

Project CI²ELO is funded by the U.S. Department of Education, Office of Special Education Programs (OSEP), to
prepare school psychologists and speech-language pathologists who have shared expertise and skills to
collaborate in the provision of classroom-based prevention-intervention services for English-learners. The funded
traineeship includes stipends and modest allowances for conference travel and professional development. A two-
year obligation of services in the public schools is required from Project CI²ELO trainees for each academic year of

Federal Eligibility Requirements - Trainees must:
 Be a citizen or national of the United states; or
 Be a permanent resident of the United States or its commonwealths or territories, or
 Present U.S. Immigration & Naturalization Service documentation of being in the U.S. for other than a
    temporary purpose, with the intention of becoming a citizen or permanent resident.
Project Eligibility Requirement - Trainees must:
 Be a full-time student in good standing in the SDSU school psychology program or in a school credential
    program in speech-language pathology,
Priority is given to trainees that:
 Have experience in multilingual schools and/or with English-learners and/or
 Have proficiencies in a high needs language in California schools.

                                            PROJECT REQUIREMENTS

Trainees supported by this Project will complete 3-units of CSP 740 Seminar & Practicum: Collaborative
Prevention-Intervention each semester and in addition to the general requirements of their graduate-credential
programs. This course includes the following:
 An intensive Institute (1.5 days, Fri/Sat) in September, January, and May.
 An intensive project collaboration seminar (Friday afternoons) including discussion of readings and practicum
    experiences, cross-disciplinary presentations, and peer coaching.
 An ongoing transdisciplinary practicum (4 hrs/wk, TBA) in a multilingual elementary school.
 Weaving of specialty content into regular program coursework, e.g., class discussions, papers, case study
 Development & maintenance of a cumulative project portfolio.

Additional project requirements:
 Documentation of knowledge base for services to English-learners by taking the California Teachers of English
   Learners (CTEL) exam until passing all components, even if beyond tenure on the project.
 Professional conference participation (i.e., CEC or comparable) – advanced trainees are encouraged to present
   a poster or panel.
 Participation in project business meetings and special activities (e.g., retreats, field trips).
 Participation in project evaluation procedures (e.g., completion of evaluation forms, meetings with external
 Signed agreement to the federally required service obligation of two years public school service to students
   with or at risk of disabilities for each year of project support.

I hereby certify that:
(a) I meet the federal and project eligibility requirements,
(b) I have provided an honest portrayal of myself in the Project Application,
(c) I understand and agree to meet all project requirements,
(d) I understand that continued participation in and funding from this project is contingent upon satisfactory
     completion of project requirements and satisfactory progress in my graduate program,
(e) I understand that involvement in and support by this project is for a maximum of two years,
(f) This project carries a Service Obligation and I have completed that form, and
(g) I have made a copy of this agreement for my own records (to be included in Project portfolio).

signature                                                                                       date

                      please print your name here                                           student number
                                    Acknowledgement And Acceptance Of Service Obligation
                                             For Support From Project CI²ELO
                                                   Fed ID #H325K100413
Project CI²ELO is funded by the U.S. Department of Education, Office of Special Education Programs (OSEP), to prepare school
psychologists and speech-language pathologists who have shared expertise and skills to collaborate in the provision of classroom-
based prevention and intervention services for English-learning students who have or are at-risk of high incidence disabilities in
California's public schools. The funded traineeship includes semester and monthly stipends, and modest allowances for conference
travel and professional development. In return for this scholarship, a two-year service obligation is required from Project CI²ELO
scholars for each academic year of support.
“Scholarship” refers to all types of financial assistance received from the project (e.g., stipends, allowances). The service
requirement is based on the period for which the scholar receives assistance, not on the amount of assistance received.
The service obligation provisions of the federal regulations specify that the scholar must serve in a position in which the individual
spends a majority of his or her time providing special education, related, or early intervention services in the schools. Part-time
employment is accumulated toward meeting the equivalent of the full-time service obligation. Supervisors, researchers, and post-
secondary faculty can qualify if they spend a majority of their time with employees, research, or students involved with providing
special education, related, or early intervention services in the schools.
Federal regulations provide for an additional three years beyond the number of years required by the Act to complete the service
obligation. Thus, a scholar with a two-year service obligation, for example, has five years to fulfill that requirement.
The full-time yearlong School Psychology Internship (or its part-time equivalent) may be applied as the first year of full-time
service obligation if the intern does not receive a scholarship from the project during that internship.
The regulations apply to training program dropouts in the same manner as other scholarship recipients. Dropouts who received
scholarship assistance and are not able to meet their service obligation (due to lack of qualifications) must payback their
Exemption to the repayment requirement will be granted if the scholar (a) is unable to continue the course of study or fulfill the
service obligation because of a disability that is expected to continue indefinitely or (b) has died.
Deferral of the service obligation and/or repayment requirement may be granted during the time the scholar (a) is engaging in a
full-time course of study at an institution of higher education, (b) is serving, not in excess of three years, on active duty as a
member of the armed services of the United States; (c) is serving as a volunteer under the Peace Corps Act; (d) is serving as a full-
time volunteer under Title I of the Domestic Volunteer Service Act of 1973, (e) has a disability which prevents the individual from
working for a period not to exceed three years; or (f) is unable to secure employment as required by the agreement for reason of
the care provided to a disabled family member for a period not to exceed 12 months.
Scholars are required to notify the Project CI²ELO office of changes in address, employment setting, or employment status
throughout the duration of the service obligation and their progress toward meeting the work requirements.
If a scholar fails to meet the terms and conditions of this scholarship agreement, or to obtain a deferral or an exemption, the scholar
must repay all or part of the scholarship assistance to the U.S. Secretary of Education as follows: Amount to be repaid is
proportional to the service obligation not completed. The Secretary charges the scholar interest on the unpaid balance owed, and
may impose reasonable collection costs. (1) Interest on the unpaid balance accrues from the date the scholar is determined to have
entered repayment status; (2) any accrued interest is capitalized at the time the scholar's repayment schedule is established; (3) no
interest is charged for the period of time the scholar's repayment schedule is established.
A scholar enters repayment status on the first day of the first calendar month after the earliest of the following dates, as applicable:
(1) the date the scholar informs the Program that he or she does not plan to fulfill the service obligation under the agreement; (2)
any date when the scholar's failure to begin or maintain employment makes it impossible for that individual to complete the service
obligation within the number of years required; (3) any date on which the scholar discontinues enrollment in the course of study.
The scholar must make payments to the Secretary that cover principal, interest, and collection costs according to a schedule
established by the Secretary.
I hereby acknowledge a two-year service obligation in return for a traineeship-scholarship from Project CI²ELO for one academic
year. I understand and accept the terms of service obligation as well as the payback provision of this agreement. I will notify the
Project CI²ELO office of changes in address and employment setting/status throughout the service obligation period and will
complete the annual follow-up forms to communicate my progress toward fulfilling the service obligation.

Signature ______________________________________________                  Date ___________________________________

Printed Name ___________________________________________                  Social Security #_________________________

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