CALIFORNIA STATE UNIVERSITY, SAN BERNARDINO



California State University, San Bernardino

APPLICATION TO SCHOOL PSYCHOLOGY Ed.S. and CREDENTIAL PROGRAM (PPS)

If accepted to this program, I will abide by the ethical principles as stipulated by the National Association of School Psychologist (NASP) and the American Psychological Association (APA). Moreover, if admitted, I agree to join NASP as a student member and purchase liability insurance.

Name: ______________________________ Signature: ___________________________

Address: _____________________________Birthdate: ___________________________ Social Security #: _____________________

City: ________________________________State: ___________ Zip: ______________

Work Phone: Home Phone: Cell Phone: Email:

Gender: ___Male ___Female Ethnicity:

Do you qualify as a person with disabilities under the Americans with Disabilities Act or Section 504 of the Rehabilitation Act?

Yes No

Are you a Veteran? ___Yes ___No Have you ever been convicted of a felony? ___Yes ___No

Are you currently being treated for any physical, emotional, or substance abuse disorder that might impair your ability to function as a school psychologist?___Yes ___No

YEAR INSTITUTION

Which degrees have you obtained? BA/BS ______________________________________________________

MA/MS ______________________________________________________

PH.D./PSY.D. ______________________________________________________

Please list credentials or licenses:______________________________________________________________________

Number of years of teaching experience: _____ Number of years of counseling experience: _____

Please list bilingual skills: ________________________________________

CCTC stipulates that students must have some training in technology. Please list your technology expertise and/or training below (e.g. Microsoft Word, Powerpoint, Library Search Engines, Excel, SPSSX, Corel, etc...).

Please attach a typed, 300 - 600 word personal statement addressing why you wish to become a school psychologist. Your statement should address what personal and professional qualities you would bring to the practice of school psychology. Finally, your statement should list and address what you believe to be the biggest issues facing school psychologists in today's public schools. You will be evaluated for writing skills

California State University, San Bernardino

SCHOOL PSYCHOLOGY Ed.S. and CREDENTIAL PROGRAM (PPS)

Professional Reference

Applicant: ___________________________________

The above named person is applying to the School Psychologist Credential Program. Please rate the applicant on the following qualities or skills compared to other school psychologists or graduate students you have known.

| | | | | | |

|Quality or Skill |Top 50% |Top 25% |Top 10% |Top 5% |Top 1% |

| | | | | | |

| | | | | | |

|1. W Writing Skills | | | | | |

| | | | | | |

|2. V Verbal Skills | | | | | |

| | | | | | |

|3. In Interpersonal Skills | | | | | |

| | | | | | |

|4. Pr Professionalism | | | | | |

| | | | | | |

|5. Pe Personal Integrity | | | | | |

| | | | | | |

|6. Po Potential for Graduate Study | | | | | |

| | | | | | |

|7. Cl Clinical Skills | | | | | |

| | | | | | |

|8. C Commitment to Public Education | | | | | |

| | | | | | |

|9. C Capacity to Work Independently | | | | | |

| | | | | | |

|10. Knowledge of Special Education | | | | | |

|Programs | | | | | |

| | | | | | |

|11. Computational Skills | | | | | |

| | | | | | |

|12. Cultural Competence | | | | | |

Evaluator's Name: ___________________________________

Evaluator's Position: _________________________ Date: ________

Please attach a letter detailing your knowledge of the applicant's work and potential to function as a school psychologist. Please address the qualities or skills rated above paying particular attention to the applicant's verbal and written communication skills. Completed rating form and letter of reference should be returned to:

Dr. Brett Nelson, Coordinator

School Psychology Program

Department of Educational Psychology and Counseling

California State University, San Bernardino

5500 University Parkway

San Bernardino, CA 92407-2397

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