Waiting List: KSALT Basic Language Skills Introductory Course Application Summer 2021 Cohort

Applicant’s Contact Information

Name *

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Middle

Last

Maiden Name

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Home Phone

Email *

Email

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Employer

Employer/School Name *

Employer/School Address *

Address Line 1

Address Line 2

City

State

Zip Code

Work Email *

Email

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Current Position *

Grade Level *

Years in Current Position *

Principal/Supervisor Name *

First

Last

Previous Positions

Certifications

List all Teacher Certificate(s) *

Your name as you want it to appear on your Certificate

Education

Institution *

Degree Awarded *

Date of Graduation Month *

Date of Graduation Year *

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Institution (2)

Degree Awarded (2)

Date of Graduation Month (2) *

Date of Graduation Year (2) *

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Institution (3)

Degree Awarded (3)

Date of Graduation Month (3) *

Date of Graduation Year (3) *

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Institution (4)

Degree Awarded (4)

Date of Graduation Month (4) *

Date of Graduation Year (4) *

Choose one *

I will Upload College/University Transcripts Here
I will email my College/University Transcripts to ksalt.training@ksfw.org

File Upload

Click or drag files to this area to upload. You can upload up to 5 files.

Professional References

An email requesting your reference will be sent to the email address you provide, as well as to yours.

Reference #1

Reference #1 Name *

First

Last

Reference #1 Position/Relation *

Reference #1 Cell Phone *

Reference #1 Email *

Reference #2

Reference #2 Name *

First

Last

Reference #2 Position/Relation *

Reference #2 Cell Phone *

Reference #2 Email *

Acknowledgement

By signing below, I acknowledge that I understand that letters of recommendation are submitted as part of the selection criteria for admission to the KSALT Training & Preparation and I hereby expressly and voluntarily waive any and all access rights I might have to such recommendations under the Federal Family Educational Rights and Privacy Act (FERPA), any state law, or any other laws, regulations or policies.

Signature *

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Date *

Additional Requirements

1. Attach a Statement of Purpose. The Statement of Purpose demonstrates your competence in speaking and writing the English language and your ability to think critically. The Statement of Purpose should be a 2-3 page (500-700 words) written statement of how your career goals would be enhanced by realizing the goals of the KSALT program. Write a statement explaining why you wish to undertake this program. It should include experiences that prompted your interest in the field of dyslexia and your motivation for becoming an academic language therapist. Feel free to type it in another program, copy and paste here. *

Click or drag a file to this area to upload.

2. I have scheduled an interview with the Director of Key School Academic Language Therapy (KSALT) Training & Preparation Program (required). *

Yes
Not yet

3. I hereby state all information provided on this form and in the attached materials is true and complete. I understand that any false statement may be cause for exclusion from this program.

Signature *

Date *

4. Statement of Financial Commitment: I understand and agree upon the payment terms of the Key School Academic Language Therapy (KSALT) Training & Preparation Program as itemized below:

BLS Deposit * • $500.00 – due upon official acceptance to the program.

Course** • $2389.00 ($1,889.00 after deposit is paid) Balance is due on or before June 18, 2021 or deposit is forfeited.

Signature *

Date *

*Please note this application is to join the BLS waiting list.