INSTRUCTIONAL FACULTY APPLICATION 2017-18 To apply for an Instructional Faculty position in the District Intern Program, applicants must complete this form, be recommended by their current Principal/Supervisor, and meet the following criteria:• Three or more years of successful classroom experience.• Experience in developing and delivering Professional Development (PD) and/or College-Level Courses (CLC) for adult learners.• Strong knowledge and experience in the implementation of District Initiatives.If you have questions regarding the Instructional Faculty Application Process, please email DistrictInternProgram@lausd.net or call 213-241-5466. Question Title * 1. First Name (indicated on your Credential). Question Title * 2. Last Name (indicated on your Credential). Question Title * 3. Middle Name. Question Title * 4. What Teaching Credential(s) do you hold? Check all that apply. Multiple Subject Clear. Multiple Subject Preliminary. Single Subject Clear. Single Subject Preliminary. Mild Moderate Disability Specialist Clear. Mild Moderate Disability Specialist Preliminary. Moderate Severe Disability Specialist Clear. Moderate Severe Disability Specialist Preliminary. Autism Spectrum Disorders Added Authorizations. Early Childhood Special Education Credential. Early Childhood Special Education Added Authorization. Administrative Services Credential Preliminary. Administrative Services Credential Clear. Pupil Personnel Services Credential. Certificate of Eligibility Administrative Services Credential. Other Education Credentials. Question Title * 5. Personal Information. Street Address. City / Town. ZIP / Postal Code. Mobile Phone. Question Title * 6. Professional Information. Current Position/Title. * Location Name. Location Code. * Education Service Center. Employee Number. Email Address (LAUSD). * Work Phone. * Question Title * 7. Beginning with the most recent, list the College/University and Degree attained. College/University, Degree (1) College/University, Degree (2) College/University, Degree (3) College/University, Degree (4) Question Title * 8. List all Professional Organizations in which you are currently involved, along with your role. Organization, Role (1) Organization, Role (2) Organization, Role (3) Organization, Role (4) Question Title * 9. List the most current Professional Development (PD) and/or College-Level Courses (CLC) that you have delivered within the last two years, beginning with the most recent PD/CLC. Indicate for each PD/CLC (a) Topic, (b) Audience, (c) Date(s) and (d) Supervising Administrator. PD/CLC (1) PD/CLC (2) PD/CLC (3) PD/CLC (4) Question Title * 10. Are you currently an LAUSD Mentor or have you previously been a Mentor? I am currently a Mentor. I have previously been a Mentor. I have never been a Mentor. Question Title * 11. Are you interested in applying to be a Mentor this year? Yes. No. Question Title * 12. Who referred you to the DI Program? Please list all applicable personnel. Question Title * 13. Have you ever received a Notice of Unsatisfactory Service/Act or a Below Standard Evaluation? Yes. No. Comments Question Title * 14. Provide two references, including your Principal/Supervisor. PRINCIPAL/SUPERVISOR: Name, Email, Phone OTHER: Name, Title, Email, Phone Question Title * 15. Your Supervisor Endorsement Statement is required to complete your application. Print out the form and obtain the required signature. Scan the signed document. Email the signed document and your current resume to DistrictInternProgram@lausd.net. Your application will be reviewed once it is received. I will email the signed Supervisor Endorsement Statement and my current resume to DistrictInternProgram@lausd.net within one week of submitting this Application. Question Title * 16. I certify that all of the information in this application is true and correct. I understand that the District Intern Program will verify this information. I acknowledge that some of the ratings and results of my performance may be confidential. I agree. I do not agree. Digital Signature: type your full name below. Done!