EPIC Mild to Moderate Student Interest

If you are interested in receiving information on the MIld to Moderate Education Specialist Credential Program in the future, please complete this brief survey.

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* 1. Today's Date

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* 2. Name

Last Name

First name

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* 3. Contact Information

Telephone number

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* 4. Employment

Place of Employment

Name of District or County Office

Current Position

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* 5. At this time, I have met the following requirements (check all that apply).

Bachelors Degree

California Basic Educational Skills Test (CBEST)

Have taken a course on U.S. Constitution or passed an exam

California Subject Examinations for Teachers (CSET)

Child Development Course

EPIC Mild to Moderate Student Interest

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* 1. Today's Date

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* 2. Name

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* 3. Contact Information

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* 4. Employment

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* 5. At this time, I have met the following requirements (check all that apply).

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* 6. Name of College or University where you earned your Bachelor's Degree.

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* 7. Comments