Adult Learning Disabilities Certificate Program Application

Application Instructions

Please note: * (asterisk) Indicates a required field.

Applicant Information

Personal information included on this form will be kept confidential in order to protect against unauthorized disclosure.

First

Middle

Last Name

(Maiden Name, Previous Name)

(mm/dd/yyyy)

Address 1

Address 2

City

State

Zip

Home

Work

Cell

Voluntary Student Demographic Information

The College of Continuing Education at Sacramento State is committed to providing equal opportunity in education. A critical element of our commitment to diversity lies in our ability to collect and assess student demographic data. Your response to the voluntary student demographic information would be very helpful and much appreciated

Please identify your age

Please identify your gender

Please identify your ethnicity origin and/or race

Please identify your highest degree or level of education

Academics & Experience

 

Academic Preparation Add More

Please list all post-secondary institutions from which you have been granted degrees/certificates/credentials and from which you have taken relevant coursework.

Name

Location

Enrolled From (mm/dd/yy)

Enrolled To (mm/dd/yy)

Degree

GPA

Date Issued

No. of Units

Experience Add More

Work and/or Educational Experience (teaching, counseling, etc.)

Institution/Agency

Title

Dates (list most recent first)

Hours per Month

Brief Description of Duties

(200 characters left)

Other Experience in Serving Adults with Learning Disabilities Add More

If additional space needed, please attach supporting documents.

Institution/Agency

Title

Dates (list most recent first)

Hours per Month

Brief Description of Duties

(200 characters left)

Additional Information

Participation in, or successful completion of, the Adult Learning Disabilities Program: Certificate of Academic Achievement does not confer any national or state credential or licensure and is not a guarantee of employment. Completion of the coursework in this program does not qualify participants to make psychological diagnoses or to provide counseling. This program partially meets the requirements for a learning disabilities specialist position as defined by Title 5 of the California Code of Regulations.

I certify under penalty of perjury that I have provided complete and accurate responses to the items listed on this application. I further certify that all official documents submitted in support of this application are authentic and unaltered records that pertain to me. I have read and agree to comply with the statements listed above.

An application fee of $30 will be collected after eligibility has been determined. You cannot be enrolled into the program until the application fee has been collected.

Privacy Policy:

The College of Continuing Education respects your right to privacy. Any information given to us when requesting course or program material will be used solely for the purpose of answering or responding to your request. We do not sell or otherwise distribute your personal information. We may, however, use it to provide you with advanced notices of our course offerings. If at any time you wish to be removed from our mailing lists, you may contact us and your request will be processed immediately.

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