You must have JavaScript enabled to use this form. 1 Start 2 Projects 3 Student Interests 4 Demographics 5 Complete Contact Information 1. Name (First & Last): * 2. Phone Number: * 3. Email: * 4. Home Address Line 1: * 5. Home Address Line 2: 6. City, State, Zip Code * Background Information 7. Where are you enrolled? * Cleveland State University Tri-C Other... 7. Where are you enrolled? Other... 7a. CSU ID: * 7b. Current Academic Level/Status: * Associates Level Bachelor's Level Master's Level Doctoral Level Unknown 7c. What is your major/license? * Early Childhood: PK-5 Middle Childhood: 4th-9th English, Math, Science, Social Studies Special Education: K-12 mild/mod Special Education: K-12 Mod/int AYA: 7th-12th English AYA: 7-12th Math AYA: 7th-12th Science AYA: 7th-12th Social Studies World Language: K-12 French World Language: K-12 Mandarin World Language: K-12 Spanish DREAM: Pk-5, ECIS, and TESOL Speech Language Pathology Other... 7c. What is your major/license? Other... 8. Do you have an FBI/BCI Background check? * Yes No 8a. If yes, when does it expire? If unknown, please specify. * 9. Means of transportation? * Car Walk/Bike Bus Para-Transit None 9a. If none, please describe situation: * 10. Are you currently in a field Class? * Yes No 10a. If yes, please state the name of the class: * Examples: Rotation 1-3, Step 1 (EUT 201/202), Classroom, EDB 242, Interactions, Yes but I do not know the name of the course. 11. Do you speak another language? * Yes No 11a. If yes, please describe: * Leave this field blank
