EDUCATIONAL LEADERSHIP PROGRAM

Application Packet for

Clear Administrative Services Program
PROGRAM REQUIREMENTS
Complete the application included in this packet and submit to:

Los Angeles County Office of Education

Educational Leadership Program
Attention:
Shannon Wilkins, Program Administrator
9300 Imperial Hwy., ECW 232
Downey, CA 90242
Submit copies of current California administrative services credential(s)

APPLICATION CHECKLIST
Complete application
Include resume
Include copy of Preliminary Administrative Service Credential or receipt from the Commission on
Teacher Credentialing confirming your application
Review job classification and requirements of your current position to determine if you are considered
an administrator and must activate your preliminary credential
Include check for $1000 or Purchase Order made payable to LACOE

This will be applied to your tuition if you are accepted into the program

If you are not accepted into the program, checks will be shredded and money orders returned
If your district has signed for fiscal responsibility (see page 6) no deposit check is required

Questions?

Email - wilkins_shannon@lacoe.edu for more information

or

boyce-jenks_stacy@lacoe.edu

APPLICATION REQUIREMENTS, continued

1.

PERSONAL INFORMATION

Last Name__________________________ First Name______________________ M______ Former______

Home Address____________________________________ City_______________________ Zip_________
Personal Phone (______)__________________ Personal Email_________________________________
District, Charter or Private School Name_______________________ School Name/Work Site______________
Current Supervisor________________________________________ Title______________________________
Phone_(______)____________________________________Email____________________________________

Gender:

Male

Female

Decline to state

Language:

English is my first language.

First spoken language:_______________

I also speak:____________________

Ethnicity: Mark all that apply.

Hispanic or Latino

Black or African American

American Indian or Alaska Native

Native Hawiian or other Pacific Islander

Asian

White

Two or more races

APPLICATION REQUIREMENTS, continued

2.

PROFESSIONAL EXPERIECE

Total Years of Administrative Experience

Position(s) Held
School Name/Address

Work Ph

Work Email

Position(s) Held__________________________________________________________________
School Name/Address_____________________________________________________________
_______________________________________________________________________________
Work Ph_______________________Work Email________________________________________
3. EDUCATIONAL BACKGROUND
Degrees Earned (list degree, date, and Institution for each):
Degree

Institution

Date Earned

GPA

California Credentials (List exact title of each):

Credential

4.

Institution

Expiration

Military or Medical Leave

Are you currently on or planning to be on leave?

No

Yes

Planning

Effective date_________________

Out of State
Yes
No

On Extension
Yes
No

APPLICATION REQUIREMENTS, continued

5.

DESCRIPTION OF WORK ASSIGNMENT (to be used for Induction Process)

Please describe your administrative position. Include position title, responsibilities, demographic of
assignment (i.e, student body API, socioeconomic, and any designations (Turnaround School, Program
Improvement, Distinguished School, etc.).

APPLICATION REQUIREMENTS, continued

EDUCATIONAL LEADERSHIP PROGRAM

Verification of Administrative Employment
1. Personal Information Applicants Full Legal Name:
____________________________ _______________________ ______________________________
(First)

(Middle)

(Last)

2. Employing Agency
Title of Administrative Position: __________________________________________________________
Date Initial Employment in an Administrative Position is to begin: ______________________________
Name of Employing Agency: ____________________________________________________________
Mailing Address: _____________________________________________________________________
______________________________________ ____________ ________________
(City)

(State)

(Zip)

County of Employment: _________________________ Telephone: ___________________________

Name of Immediate Supervisor: ________________________________________________________
Position: ___________________________________________________________________________
Approved by:

_________________________________________ _________________________________________
Name of Employer or Designee (print or type)

Title of Employer or Designee

_________________________________________ _________________________________________
Signature of Employer or Designee

Date

APPLICATION REQUIREMENTS, continued

EDUCATIONAL LEADERSHIP PROGRAM

Candidate Commitment Letter
Please indicate your understanding by initialing each statement:
_________ I understand Leadership Coaching is a two year commitment.
_________ I understand Leadership Coaching fees are $4900 each year of the two (2) year program.

Clear Credential Financial Obligation Option

Please indicate method of payment for the program fees, sign and return with your application.
Items marked with an asterisk require the signature of the Superintendent or Designee.
_____ * My employer will pay for all costs associated with the Credential Program for two years.
Person responsible for financial obligation must sign below accepting responsibility as the
District Representative.
OR:
_____ * My employer will contribute $__________ per year towards the Credential Program, I will
be responsible for the balance. Person responsible for financial obligation must sign
below accepting responsibility as the District Representative.
OR:
_____ I will pay all costs associated with the Credential Program for two years.
____________________________________
Credential Candidate (print name)

___________________________________
* District Representative (print name)
___________________________________
* District Representative Title

____________________________________
Signature

___________________________________
* District Representative Signature

____________________________________
Date

___________________________________
* District Representative Phone Number
___________________________________
* District Representative Email