Profectum AcademyApplication
Educators Certificate in the DIR-FCDModel
We welcome your application to the Profectum Academy and look forward to your joining us.
1)This application is for those who would like to obtain an Educatorscertificate from the Profectum Academy. Prior experience or training in the model is not required.
2)Be sure to answer all questions or indicate N/A where appropriate.
3)Please email your completed application and curriculum vitae/resume to . Please be sure to send in all of your materials at one time. This will expedite the review of materials and your acceptance into the program.
4)Upon your acceptance to the program you will be emailed a letter of acceptance followed by details for the course and further instructions.
Instructions for completing this form: Click in the empty box next to the information requested and begin typing. The box will expand automatically to accommodate your entry.
DateSent: / E-Mail Address:Self-Referred: / (Y/N) / Referred by:
Where did you hear about the program?
I.Name and Information:
Last Name: / First Name: / M.I.Degree: / Occupation:
License Type: / License State: / License #:
Other Credentials:
Do you work in the field of education?: (Y/N) / Early Intervention? (Y/N)
II.Home Address/Phone:
Street/Apt. #:City: / State/Province: / Zip/Post Code:
Country:
Home Phone: / Home Fax: / Cell Phone:
Home E-Mail:
III. Work Information:
Number of children and hours per week you provide |Intervention: / Assessment: / Admin/Reports/Other:
Will you be able to present Floortime™ video clips of yourself and a child, parent and child?
- Note: Videos are shown in small training groups as part of your presentation. Showing video clips is required. You must be able to present a minimum of 3 children over the course of the year in which you are enrolled (2+ in tutoring and 1 for the final vignette).It is your responsibility to obtain the appropriate permission from the agency and/or parent.
Are you also the parent of a child with special needs? (Y/N)
If so, do you now work with other children with special needs? (Y/N)
*You only need to complete this section if it is not on your CV/Resume.
1.Current PositionSince:Title:
Name of Organization/Practice:
Address:
City: / State/Province: / Zip/Post:
Country:
Work Phone: / Work Fax:
Supervisor:
2.Previous PositionDates:
Title:
Name of Organization/Practice:
Address:
City: / State/Province: / Zip/Post:
Country:
Work Phone: / Work Fax:
Supervisor:
IV.Professional Qualifications, Training and/or Education
*You only need to complete this section if it is not on your CV/Resume.
1. Please list all educational experience
Institution / Major/Minor / Program Dates / Degree/Credential / License # and Date(if applicable)
a.
b.
c.
2.Describe other relevant work experiences.
Position / Setting / Dates / Duration
a.
b.
V.DIR®/Floortime™ Training:
Will this be your first training experience in DIR®/Floortime™? Y/N
If not, approximately how many training courses/conferences have you attended that discussed DIR®/Floortime™? ______
Describe your goals in participating in the Profectum Academy and how you hope to integrate it into your work.
How many children will you be working with during the time of this course? Estimate
When would you like to start this course?
Group #/Course date: First preference ______Second preference ______
Signature: ______Date: ______
Thank you for completing application.
Please review your responses and be sure you have answered all questions.
Profectum Academy Basic Course in DIR®-FCD Certificate Program Application