TVCertification

Application (Non-Degreed)

Date:
Name:
Last / First / Middle
Indicate other identifying name(s) that may appear on your documentation:
Driver’s License Number: / State: / Expiration Date:
Date of Birth: / Gender: / Male / Female
Month/Day/Year
Address:
Street / City / State / Zip
Telephone: / ( ) / ( )
Daytime Phone Number / Cell/Evening Phone Number
E-mail address: / Fax Number:
Last school experience:
School Name / School District

If retired, date of retirement: ______

Select tutoring areas: EC-6 ______Grades 4-8 ______Grades 8-12 ______

Pre-College ______College-level ______

Select several areas: English _____ Mathematics _____ Science ______Study Skills ______

Social Security Number ___-___-_____ (You will be issued an ACC student number for TV tracking purposes only.)
Have you served in the military?  No  Yes
Branch / From / To
Education: / Applicable Scores:
ACT/SAT: ______
THEA: ______
Compass: ______
Other: ______
All Colleges/Universities Attended / City and State / Type of Degree Granted Major/Minor / DATES: From To
  • Bachelor’s Degree required for Master Level
  • Associate’s Degree required for Advanced Level
  • High School credits and teacher recommendation required for Regular Level
Additional Certifications/ Licensure
Certifications/ Licensure /

Number

/ Issued by / Effective Date / Expiration Date

Do you possess a certificate which is currently suspended, revoked, or pending such action in any state? If yes, explain:

Work and/or Teaching Experience: List most recent work experience first.

From/To
(Mo./Yr.) / Employer
Address, City, State, ZIP / Name of Supervisor and Title / Work Performed
Telephone Number / Reason for Leaving
From/To
(Mo./Yr.) / Employer
Address, City, State, ZIP / Name of Supervisor and Title / Work Performed
Telephone Number / Reason for Leaving
From/To
(Mo./Yr.) / Employer
Address, City, State, ZIP / Name of Supervisor and Title / Work Performed
Telephone Number / Reason for Leaving
Criminal Background: To obtain your tutoring certification, you must be hired to tutor, and having a criminal history may keep you from employment.According toH.B. 1498 (TEC21.917), Texas school districts will run a Criminal Background Check (CBC) to obtain criminal history information on every employee, candidate for employment, and observer in schools.A criminal history may keep you from employment with a school district ANDfrom acceptance into the TV Certification Program.
Have you ever been convicted of a crime other than a traffic ticket or parking violation?
No Yes
If yes, on the space provided below, state the crime/s, location of the court where you were convicted, date of conviction and current disposition or status, including length of probation, parole, fine or time served.Attach additional sheets if necessary.
**Have you received deferred adjudication for a crime ?  No  Yes
Note: you must answer yes, even if you have completed the deferred adjudication and you have been advised or do not feel that the crime is or should be reflected on your record.
If yes, on the space provided below, state the crime/s, location of the court where you received deferred adjudication, date, and a current disposition or status.Attach additional sheets if necessary.
**If you have received deferred adjudication for a crime, we encourage you to contact a lawyer to have the incident expunged from your record.

Please attach additional sheets if necessary

Tuition:We encourage you to pay for TV Certificationthrough ACC’s Tuition Installment Plan.

Tutors with Vision Certification Program Fees / Cost / Due Dates
Application and course registration - EDTC 1070 / $300 / December 15/ June 1/ August 30

Refunds: The ACC Continuing Education refund policy: 100% prior to the weekday before the first class day, and 100% if class is canceled by ACC. After classes begin, consult the table below. The number of days listed refers to business days (M-F), not class meeting days. Classes that are ONE day long must be dropped before the class starts for any type of refund to occur. YOU MUST CONTACT THE TLC STAFF IN WRITING. See Refund policy on the Continuing Education website in the schedule.

Candidate Agreement:

  • I agree to abide by the policies, procedures, rules, and regulations of the Austin Community College Tutoring Certification Program. Failure to do so will result in dismissal from the program. I understand that I must adhere to the program requirements to complete preparation and certification at one of three levels: regular, advanced, and Master. I will be evaluated at various points during training, and must meet all requirements in order to stay in the program. I will be recommended for level certification based on successful completion of training with approval of Director and Facilitator.
  • By applying to and registering with Austin Community College, I agree to abide by the Student Discipline Policy and Student Rights and Responsibilities regulations published in the ACC College Catalog and Student Handbook.
  • I certify that statements by me in this application are true, complete, and correct to the best of my knowledge and belief. I understand that any false statement, misrepresentations, or omission(s) made by me on the application or during the application process shall be grounds for refusal to be admitted to or withdrawal from the Austin Community College tutoring Certification Program.
  • Confidentiality Statement- I am applying for the TV Certification Program at Austin Community College. I hereby give ACC permission to make inquiries concerning my performance in the past and general character. I agree that the information will not be disclosed to me, but will be treated as confidential by ACC. I waive any right to see this information and release ACC’s TV Certification Program from liability involved with the investigation.

I certify that all of the above information is true, accurate, and complete. I understand that any misrepresentation or willful omission of facts shall be sufficient cause for disqualification of this application from further consideration.

Print Name:
Last / First / Middle
Signature of Applicant: / Date:

(Signature may be electronically administered.)

If applicant is younger than 18, signature of parent/guardian:

Parent/guardian signature: ______

For High School and College Age students

Peer tutoring and Service Learning are both important components of the learning process that reach students in ways not directly through school professionals. Consider working with students to enhance your own learning and support them through these channels.

In addition to the above information, provide:

Reason why you would like to peer tutor:

Reason why you would like to participate in Service Learning:

Are you a member of your school’s Honor Society? ______Name of group and campus ______

Honor Society Leader’s name and email information ______

Proficient area to teach:

Math, highest level ______

English, highest level ______

Science, highest level ______

A teacher recommendation is needed for each level (make copies of next page for each area and submit with application).

Professional Reference Form for HS/College Tutors

Return this recommendation form directly to:

TLC Coordinator

5930 Middle Fiskville Rd

Austin, Texas78752-4390

512.223.7854 / Fax: 512.223.7030

Applicant's Name ______has applied to ACC's Tutors with Vision Certification Program. Will you assist us by sending/faxing the following information at your earliest convenience to the fax number given above? We trust that your interest in children will motivate your response.

How long have you known applicant? Dates: from to

What is/was your relationship to applicant?

Would you hire applicant? Yes No

Would you want this person to tutor your children?

Please indicate by a check mark your confidential rating of the applicant’s qualities as listed below:

Characteristic / Clearly Outstanding / Exceeds Expectations / Satisfactory / Below Expectations / Unsatisfactory
Effective Communication Skills with children and adults
Academic Preparation
Planning and Organizational Skills
Positive Attitude and Enthusiasm
Initiative
Emotional Stability and Maturity
Dependability and Punctuality
Other:

Please add additional comments on the back of this form. The applicant’s acceptance into the program is dependent on your honest evaluation and returning the form as quickly and thoroughly as possible. Thank you.

Printed Name______Daytime Phone Number ______

Address ______

Organization/Company ______

Signature ______Position ______

Teaching & Learning Center, Continuing Education, at Austin Community College