ECSEL Supplemental Application

Please complete the following supplemental application as part of your overall application to the Enhancing Capacity for Special Education Leadership (ECSEL) program. The complete list of application materials is available on the Application Information page. Applications will not be reviewed until all application materials have been received.

Applicant Information First Name: Required

Middle Name:

Last Name: Required

Email:Required

Public School Employment Current School: Required

Current District: Required

Number of Years of Professional Experience in Schools (as a Teacher or Related Services Professional: Required

Number of Years Experience as a Special Education teacher: Required

Indicate all levels taught: Required

Elementary
Middle Level
Secondary

Please list all subjects taught (at middle and secondary level):

Please list all specialist teaching or related services certifications and endorsements:

Leadership Experience in Special Education Number of years with part- or full-time release in a leadership position involved assisting other teachers with instruction (e.g., instructional coach, mentor):

Describe prior work directly related to teacher instructional leadership in special education (documented prior experience may reduce Part 1 internship requirements by as much as 200 hours):

Number of years with part- or full-time release in a district-wide special education leadership position (e.g. responsibility for coordinating a district program):

Please describe your district-level special education leadership role:

Number of years of leadership experience outside education (where you had responsibility for supervising others):

Please describe this leadership role outside education:

Assurance and Documentation of Full Program Participation Please describe how your current position will support completion of the school-level special education leadership internship requirement:

Please provide the name, telephone number, and email address of a school district supervisor who can confirm the opportunity for completing a part 1 internship in your current position:

Please provide assurance that you will be able to attend all scheduled weekend and retreat sessions of the ECSEL program. These will be held in the Seattle metropolitan area, with candidates responsible for their own transportation (and lodging, if needed). Seminar dates and location to be announced by December 1, 2013.

If you agree to the above schedule, please check “I Agree”:

I Agree

If you are unable to attend all of the proposed seminar dates, please list dates you are unable to attend:

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