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* 1. Last Name

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* 2. First Name

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* 3. Middle Name

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* 4. NOTE: Comment here if you are referred to by your middle name or a double name.

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* 5. Tech Email (ex. avessel@email.latech.edu)

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* 6. Preferred Personal Email

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* 7. Phone Number (000-000-0000)

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* 8. Certification Area

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* 9. Campus Wide Student ID (000-00-000)

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* 10. Social Security Number (NOTE: write just like this with dashes 000-00-0000. We must have for residency teaching certificate.)

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* 11. Ethnicity

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* 12. Date of Birth (ex. 06/03/1999)

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* 13. Permanent Mailing Address (Street Name or Box Number)

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* 14. City

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* 15. State (ex. LA)

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* 16. Zip Code

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* 17. Choose 1st TEAM District Choice:

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* 18. Choose 2nd TEAM School District Choice:

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* 19. List all K-12 schools attended

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* 20. DISCLOSURE STATEMENT: List any relatives that are current or former employees of the districts of interest. We must secure any special permissions needed. Include name, job title, and relationship to resident.

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* 21. Have you passed your Praxis II Exam? (NOTE: All certification exams must be passed with Tech receiving official scores by June 1 in order to be accepted to the TEAM Model Clinical Residency Program.)

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* 22. Have you passed your PLT exam? (NOTE: All certification exams must be passed with Tech receiving official scores by June 1 in order to be accepted to the TEAM Model Clinical Residency Program.)

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* 23. I UNDERSTAND THE INFORMATION LISTED BELOW:

CRRC PRAXIS RESOURCES:
1. Free materials on latechcrrc.org - password TEAM19
2. 240 Tutoring at $20/month. Email avessel@latech.edu to receive an invitation to join.

RESIDENCY COSTS:
Residency Certificate: no cost (When: May 2021)
Liability Insurance: approx. $20 (When: June/July 2021)
Background Check: approx. $50 (When: July/August 2021)

TEAM MODEL CLINICAL RESIDENCY NEXT STEPS (TIMELINE):

FEBRUARY/MARCH 2021
- Submit Residency Application ASAP to secure district placement.
- Check Tech email daily for communication from the CRRC.
- Update Mrs. Birch at crrc@latech.edu when you have evidence of Praxis registration or passing scores. Tech receives official passing scores approximately 2 weeks later. If you do not pass an exam, also reach out so we can provide additional resources and provide support in selecting next test date. 

APRIL 2021
- Those with passing official Praxis scores will be able to register for residency during advising for fall quarter in April/May.
- Attend April TEAM Model Zoom Workshop - Date TBA.

MAY 2021
- Attend May TEAM Model zoom workshop - Date TBA.
- Submission of Residency Certificate application. CRRC will submit to the Louisiana State Department of Education. 

JUNE 2021
- Louisiana Tech must receive all official passing scores for Praxis II and PLT by June 1. Admission to residency, clinical placements, and registration for fall quarter residency class will only be finalized for those meeting this  requirement.

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* 24. Attach a Preferred Photo (headshot - to be used in upcoming district/school announcements)

PNG, JPG, JPEG file types only.
Choose File

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* 25. Additional Comments/Questions.

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* 26. I certify that the information submitted above is true and accurate. On this date, I submit my 2021-2022 TEAM Model Clinical Residency Application.

Date

T