Teacher Leader Certification Academy
Los Angeles County Office of Education
SECTION ONE: APPLICANT GENERAL INFORMATION
Provide contact and teaching assignment information.

PLEASE CLICK ON THE "SUBMIT" BUTTON WHEN YOU ARE DONE.

Last Name:
Your answer
First Name:
Your answer
Home Address
Your answer
Personal Email
Your answer
Cell Number
Your answer
Home Phone Number
Your answer
Name of School District
Your answer
Current Teaching Assignment
Years of Teaching
Name of School Site
Your answer
School Site Address
Your answer
Work Email
Your answer
Work Phone Number
Your answer
Site Administrator's Name
Your answer
Site Administrator's Email
Your answer
Site Administrator's Phone Number
Your answer
Signature
Typing my name and dating below affirms that I have met the above eligibility requirements for the Teacher Leader Certification Academy and I have provided the required documentation of verification. I understand that I am not officially enrolled in the program until I receive written acceptance from the Teacher Leader Certification Approval Team and have paid the required registration fee at the beginning of each year. *
Your answer
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