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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. These are our current partner districts. Check all districts that you are interested in learning more about at the upcoming mid-year recruitment event.

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* 18. List all K-12 schools attended (ex. Weston High School - Jackson Parish) 

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* 19. DISCLOSURE STATEMENT: List any relatives that are current or former employees of the districts of interest. If it is an immediate relative (mom or dad), list all schools where they have worked. We must secure any special permissions needed. Include name, job title, and relationship to resident.

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* 20. Are you currently accepted into the Teaching Program?

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* 21. Have you passed your Praxis II Exam? Send scores to STATE OF LOUISIANA and LOUISIANA TECH UNIVERSITY!
(NOTE: All certification exams should be passed with Tech receiving official scores by June 1 in order to be fully accepted to the TEAM Model Clinical Residency Program.) This means that you will not be able to register for the fall residency class or receive a final placement until exam scores are received by the state.

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* 22. Have you passed your PLT exam? Send scores to STATE OF LOUISIANA and LOUISIANA TECH UNIVERSITY!

(NOTE: All certification exams should be passed with Tech receiving official scores by June 1 in order to be fully accepted to the TEAM Model Clinical Residency Program.) This means that you will not be able to register for the fall residency class or receive a final placement until exam scores are received by the state.

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* 23. I UNDERSTAND THE INFORMATION LISTED BELOW:

1. I must be admitted to the Tech Teaching Program.
2. All PRAXIS II and PLT scores must be sent to the State of Louisiana AND Louisiana Tech University. Make certain you mark those when registering.
3. I will follow the school district calendar as a resident so I will start the residency in August before fall quarter begins.

CRRC PRAXIS RESOURCES:
1. FREE Praxis Study guides for check out (Tuesday, Wednesday, Thursday between 9 a.m.  - 3 p.m. or email to arrange pick up).
2. 240 Tutoring is a simulated online study tool. Email avessel@latech.edu to receive a discounted membership invitation to join.

RESIDENCY COSTS:
Residency Certificate: no cost (When: May 2024)
Liability Insurance through APEL membership: approx. $20 (When: June/July 2024)
SWIVL membership: approx. $85 (When: August 2024)
Background Check: most are provided by your districts

TEAM MODEL CLINICAL RESIDENCY NEXT STEPS (TIMELINE):

NOVEMBER 2023
- Submit online Residency Application to the CRRC. 

DECEMBER 2023
- RSVP to the CRRC Mid-Year Recruitment Event - held Friday, January 12, 2024, at the Davison Athletic Complex.

JANUARY 2024
-Participate in Mid-Year Recruitment
-Participate in CRRC Residency Interview Process

FEBRUARY/MARCH 2024
- Submit Residency District Requests.
- 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 2024
- 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 2024
- Attend May TEAM Model zoom workshop - Date TBA.
- Submission of Residency Certificate application. CRRC will submit to the Louisiana State Department of Education. 

JUNE 2024
- Louisiana Tech should 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 understand that I will not be allowed during spring advising to register for residency, be placed for residency, or begin residency until all requirements are met for admission to the TEAM Model Clinical Residency Program.

Date
Time

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* 27. I certify that the information submitted above is true and accurate. On this date, I submit my 2024-2025 TEAM Model Clinical Residency Application.

Date

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