STEPHEN F. AUSTIN

STATE UNIVERSITY

Training Program in Visual Impairment

And Orientation and Mobility

Personal Data

Name:

LastFirstMiddle

Address:

Street

City State Zip

Education Service Center Region:______

Phone: ( )( )

DaytimeEvening

Email(s):

Social Security Number:

Date of application:

Have you ever been convicted of a felony? _____ yes______no

Application Area

Please check the training area you wish to pursue:

  • Teacher of Students with Visual Impairments
  • Certified Orientation and Mobility Instructor
  • Dually certified

Do you intend to pursue a Master’s degree? _____ Yes_____ No

Certifications

List all teaching certificates currently held:

Certificate or endorsementStateYear

Employment Information

Current Position:

District:

Business Address:

City:State:Zip:

Work phone: ( )Fax: ( )

Director of Special Education:

Phone number of Director:

Educational Background

List all colleges/universities attended
/ Degree /
Major
/
Date

Work Experience

From
/ To /
Name of employer (begin with most recent)
/
Position

What work experiences have you had in working with children?

What work experiences have you had in working with children or adults with special needs?

Program Stipulations

Please read the following statements carefully, and initial to acknowledge your understanding that:

______If I withdraw from SFASU, I will not receive any refund of funds paid for tuition and/or fees.

______I will be responsible for purchasing my textbooks and paying for (or arranging payment for) any expenses not expressly covered by grant stipend payments.

______I have internet access and have skills which allow me to do the following tasks:

use a word processor, open a website, complete an internet search, efficiently use email, and attach a word processing file to an email.

______I have read the information posted on the VIP Program’s website regarding the typical roles and responsibilities of TVIs and COMS and I want to work as a VI professional.

______These are graduate level classes and I will be expected to perform at a graduate level. I will be expected to spend a significant amount of time beyond class in order to successfully complete the requirements.

______Each of the courses required in this program contain field experience components which will involve my identifying, observing, volunteering with and/or in some other way interacting with students with visual impairments, their families, and/or other VI professionals.

______When I have completed this program, I MUST COMPLETE 2 years of service with students who have visual impairments for every year I receive stipends from the grant funded by Texas School for the Blind and Visually Impaired (TSBVI)/Stephen F. Austin State University (SFASU). If I fail to do this, I will be liable to TSBVI/SFASU for repayment of all stipend funds paid to me. Further, I understand that if I do not complete the program, I will be liable to pay back any stipend funds I have received.

______It is expected that at the end of my training, I will serve my “pay back” period in the state which is supporting my training.

______My application cannot be considered until my application packet is complete, including letters and supporting documentation.

______I feel, based on my current situation, that I will be physically able to complete
the payback responsibilities associated with this grant award with or without
accommodations.

Applicant’s SignatureDate

RETURN TO:Michael Munro or Donna Wood

Stephen F. Austin State University

Department of Human Services

PO Box 13019 – SFA Station

Nacogdoches, TX 75962

Fax: 936-468-1342