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.
Home Phone Number
Name of School District
Current Teaching Assignment
Teacher on Special Assignment (TOSA)
Years of Teaching
1 - 4 years
7 - 8 years
9 - 12 years
13 -16 years
17 or more years
Name of School Site
School Site Address
Work Phone Number
Site Administrator's Name
Site Administrator's Email
Site Administrator's Phone Number
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. *
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