Application for: FALL
SPRING
year
SUMMER
year
year
APPLICANT DATA SHEET
Name
Last
First
Student ID #:
Middle
Social Security Number:______________________
Fresno State Email:
Phone Number___________________________
Date of Birth: ____________________
Degree: ________________________________________________________________________________
Major
Institution
Semester & Year graduated
OR
Anticipated Graduation Semester & Year
Check the pathway that applies:
 part time student or  full time student
And
 Education Specialist Basic Program
 Mild/Moderate or  Moderate/Severe
 Education Specialist Internship Program
 Mild/Moderate or  Moderate/Severe
Application Packet Required Documents (Please submit paperwork in this order.)
DO NOT WRITE BELOW THIS LINE
1.
2.
3.
4.
5.
6.
Application Data Sheet
Documentation of University Application
Ed. Specialist Orientation Session Attendance Form
Verification of Pre-Program Field Experience
CBEST Scores R
M
W
(California Basic Education Skills Test)
CSET Scores 101___102___103___
(California Subject Examinations for Teachers)
7.
Signed Admission Interview Form/Typed
Responses
8.
Signed Medical Clearance Form
9.
Letters of Recommendation (Two Required)
10. Advising Form
11. Certificate of Clearance
12. Field Placement Information Sheet
Admitted
Technician’s Signature
Denied
Technician’s Signature
GPA: Cumulative
Last 60 Units
 U.S. Constitution
9/24/13 Education Specialist Credential
1
Application for: FALL
SPRING
year
SUMMER
year
year
ADMISSION INTERVIEW FORM
Name
Last
First
Middle
Student ID #:
Fresno State Email:
Gender: Male
Date of Birth
Female
*Schedule your interview appointment in ED 250 or call (559) 278-0250.
When you attend your interview, bring the following items with you:
1) Admission Interview Form
2) Dispositions Self-Assessment with the “Application” section completed (found on the following pages)
3) Typed responses to interview questions below
Please word process your responses to the questions below:
1.
Describe the characteristics of the best teacher you ever had.
2.
Professional Dispositions:
Collaboration
Critical Thinking
Reflective Practitioner
Professional Ethics
Valuing Diversity
Life-long Learning
What dispositions do you have that make you a strong candidate for the teaching profession?
In what teaching areas will you need support?
3.
How will you want your students to remember you?
Meets English speaking competency:
YES NO
Meets suitability for teaching requirement:
YES NO
Faculty Signature
Date
Comments:
Referrals Made At Interview:
Writing Center (278-0334)
Writing Courses for Non-Native English Speakers (278-2097)
Students with Disabilities Support (278-2811)
Speech and Hearing: Accent Reduction Services (278-2422)
Health and Psychological Services (278-2734)
9/24/13 Education Specialist Credential
2
SPECIAL EDUCATION CANDIDATE DISPOSITIONS SELF-ASSESSMENT
California State University, Fresno
Candidate: ___________________________________________________________________
Date:_____________
Circle one:
SPED 236
Application/Program Entry
SPED 175
SPED 176
The following matrix was developed based on feedback from our candidates, advisory board members and part-time faculty. Descriptors are listed as evaluation
guidelines for each of the dispositions. Included with each disposition are examples of behavioral indicators. Each indicator is offered as a suggested behavior, and not as
a conclusive determining factor. Rate yourself or the candidate you are supervising in each of the following listed behaviors as follows. Please rate the items in the table
below on a scale from 1-4:
1 = no/limited evidence/application 2 = some evidence/application 3 = satisfactory evidence/application 4 = Exceptional evidence/application
DISPOSITION: Reflection
Applies, assesses, reflects upon, and adjusts instructional strategies to advance student
learning.
Accepts and incorporates suggestions in subsequent practice.
Demonstrates self-analysis regarding one’s own strengths and weaknesses.
Ability to see one’s own contribution to identified challenges in the classroom and to make
changes as needed.
DISPOSITION: Critical Thinking
Utilizes assessment data to adjust instruction, choice of curriculum and methods of
evaluation.
Candidate’s work (e.g., case studies, group process evaluations, article critiques) indicates
an ability to identify problems and solutions.
Intentionally applies and encourages higher order thinking skills, such as analysis,
synthesis, problem recognition and problem solving with students in the classroom.
Solicits and gives thoughtful consideration to alternative and contradictory opinions.
Inquiring, creative, seeks solutions
DISPOSITION: Professional ethics
Recognizes the importance of consulting research to inform instruction for students with
special needs
Shows commitment to ethical conduct: turns in assignments on time, is punctual and
reliable in attendance, maintains professional appearance
Utilizes positive behavioral supports when managing student behavior.
Actively advocates for students and encourages student self-advocacy.
Utilizes non-biased assessments.
9/24/13 Education Specialist Credential
3
Application
(Program Entry)
1
2
3
4
SPED 175/176
(Preliminary Exit)
1
2
3
4
SPED 236
(Clear Exit)
2
3
1
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
4
DISPOSITION: Valuing Diversity
Diagnoses learners’ needs by interpreting data from diverse sources (e.g., formal/informal
assessments, student behavior and feedback, and parent responses)
Develops lessons that are interesting and engaging utilizing a variety of instructional
strategies to accommodate all learners, including those from diverse backgrounds,
experiences, and cultures.
Facilitates the academic and social inclusion of students with special needs in various
inclusive activities and environments.
Differentiates instruction to allow students who differ widely in terms of their background,
knowledge, learning styles/preferences, and orientation to school norms to reach common
standards.
DISPOSITION: Collaboration
Demonstrates the ability to work creatively and collaboratively with colleagues, parents,
and the community.
Values families as full partners in the educational process
Collaborates with general education teachers in the modification of instruction, curriculum
and assessment of students with special needs.
Communicates on a regular basis the progress of students with special needs to parents
and general education teachers.
Plans and collaborates to ensure that appropriate supports for smooth transitions are in
place.
DISPOSITION: Life-long Learning
Seeks out opportunities for professional development (e.g., attendance at workshops,
inservice trainings, conferences, membership in professional organizations) using the
information learned to improve teaching practice.
Seeks out opportunities to serve the school, students, and community (e.g., extracurricular
activities, Big Brothers, Big Sisters).
Demonstrates a positive attitude toward learning, intellectual and academic curiosity.
Presents on an area of expertise or interest to teachers and/or parents at local, state,
national or international conferences or trainings.
Candidate Signature: ___________________________________________________________________
9/24/13 Education Specialist Credential
Application
(Program Entry)
1
2
3
4
SPED 175/176
(Preliminary Exit)
1
2
3
4
1
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
Date: _____________
4
SPED 236
(Clear Exit)
2
3
4
Application for: FALL
SPRING
year
SUMMER
year
year
MEDICAL CLEARANCE FORM
Name
Last
First
Middle
Student ID #:
Fresno State Email:
Gender: Male
Date of Birth
Female
CERTIFICATION BY DIRECTOR OF STUDENT HEALTH SERVICES OR PRIVATE PHYSICIAN
This is to certify that the applicant has been tested for active tuberculosis within the last year and the
results were negative.
(EC44336 – This student is “free from any contagious and communicable disease or defect unfitting the applicant to instruct or
associate with children.”)
Date
Health Center Director or Private Physician's Signature
Office Address (If private Physician)
9/24/13 Education Specialist Credential
5
Application for: FALL
SPRING
year
SUMMER
year
year
FIELD PLACEMENT INFORMATION SHEET
(EHD 178 for EDUCATION SPECIALIST ONLY)
Name
Last
First
Student ID #:
Address:
Middle
Maiden Name
Mailing
Number, Street, Apt#
City
State
Zip
Number, Street, Apt#
City
State
Zip
Permanent
Telephone:
Home
Cell
Fresno State Email:
Gender: Male
Date of Birth
Female
Degree
Major
Institution
Year Graduated
This application does not automatically enroll you in the course. You must enroll for fieldwork as you would for
other courses, via registration procedures. Information regarding registration numbers will be sent to you upon
approval of this application. NOTE: Fieldwork courses are scheduled “as arranged”.
Please check applicable boxes:
Program Emphasis:  Mild/Moderate or  Moderate/Severe
Course that will be taken concurrently with EHD 178:
 LEE 173 or  LEE 177
All applicants who have cleared are required to attend a general orientation meeting, which is held at the beginning of
the semester. Information regarding meeting date, time and location will be emailed to Fieldwork enrollees, at the
Fresno State email address, who have cleared for admission.
Teacher candidates cannot be assigned to schools where their children attend or where immediate family members
are employed. _____________________
Family Member School Site
The process of determining placements will not start until teacher candidates have met all admission requirements
and are registered for the course. Some placement options will fill quickly.
Coordinator’s Approval (For ECE applicants only)
Date
Admission Technician Approval
Date
For Office Use Only
EHD 178: Supervisor: ______________________Master Teacher: _____________________School:______________________
9/24/13 Education Specialist Credential
6
NOW YOU ARE READY TO:
1.
Print this application.
2.
Include the additional documentation required.
3.
Place documents in order as listed on the applicant data sheet.
4.
It is recommended that you make a copy of this entire application for your records.
5.
Bring the completed application to the Education Student Services Center, Education
Building, Room 100, prior to the application deadline date or mail to:
Kremen School of Education and Human Development
California State University, Fresno
Education Student Services Center
5005 North Maple Avenue, MS ED301
Fresno, CA 93740-8025
6.
Once application has been submitted, begin checking your California State University,
Fresno email regarding your application status.
AFTER program completion and prior to applying for a Preliminary Education Specialist credential you must:
1. Complete 2042 Education Specialist credential coursework with a minimum program GPA of 3.0 and
pass all of the Teacher Performance Assessments (TPAs).
2. Pass CSET
3. Pass CBEST
4. Complete a bachelor’s degree from an accredited institution
5. Complete a course in the U.S. Constitution or pass an approved exam
6. Document the Certificate of Clearance
7. Pass RICA (Reading Instruction Competence Assessment)
8. Complete CPR certificate
A Preliminary Education Specialist credential may be awarded when the above requirements have been met.
ONLY when you are ready to apply for your Preliminary Education Specialist credential and you have questions,
contact the Credential Analyst Office:
Sherri Nakashima
(559) 278-0300
sherrin@csufresno.edu
ANY QUESTIONS? Contact the Education Student Services Center at (559) 278-0300 or visit the
Education Building, Room 100, at California State University, Fresno.
ALL REQUIREMENTS ARE SUBJECT TO CHANGE
LEGISLATIVE MANDATES.
9/24/13 Education Specialist Credential
DUE TO
NEW
7