Educational Intervention Specialist Referral Application Name First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Are you an Everyone Reading Illinois member? * Yes No If approved, may we list your email address as a point of contact? (along with preferred contact phone number) ? * Yes No Employer Name * Member Affiliation * IDA LDA CHADD Other (list below) Other Membership Affiliations Subjects * Reading Writing Spelling Math Study Skills Other (list below) Additional subjects Grade Levels * Elementary Junior High High School Adult Tutoring Location * Times * Can you tutor outside of your home or office location? * Yes No Structured Literacy Training Approaches for which you have completed a supervised practicum. Class Date MM DD YYYY Location/Site Instructor/Organization Class Date MM DD YYYY Location/Site Instructor/Organization Class Date MM DD YYYY Location/Site Instructor/Organization EDUCATION TRAINING College/University Year Location Degree Earned College/University Year Location Degree Earned CERTIFICATIONS Certification Year Location Instructor/Organization Certification Year Location Instructor/Organization Certification Year Location Instructor/Organization REFERENCES Full Name Relationship Company Phone Email Address Full Name Relationship Company Phone Email Address Full Name Relationship Company Phone Email Address I certify that my answers are true and complete to the best of my knowledge. I am attesting to my statement of all credentials, education, degrees and licenses and that I have not been convicted of any felonies or crimes. If this application leads to approval, I understand that false or misleading information in my application may result in my name removal from the referral list. I also understand that my signature provides permission for a member of the committee to call my listed references and also it is an indication that the committee may ask the applicant to provide written letters for reference. Respond time from Everyone Reading Illinois in regards to decision, is usually within one month from the receipt of the completed application in the office. * By typing your full name below, you agree to the terms and conditions of this agreement. Thank you!
