Instructional Services
Attn: Diana Ceja, Administrator
P.O. Box 868, Riverside, CA 92502-0868
Phone: (951) 826-6304 / Fax: [951] 826-6937
E-Mail:
Riverside County Seal of Multiliteracy: Intent to Apply
Please type your information into the fields below. Entries may be submitted by email any time after Monday, May 1, 2017, but must be received by Friday, August 25, 2017, at 5:00 p.m.
Student Information (ALL sections must be typed in order for the application to be considered.)
Date: / Grade Level:Name: / Date of Birth:
Street Address: / Home Phone:
E-mail:
City, Zip Code: / Cell Phone:
School Information
District: / School Program Coordinator:
School: / E-mail:
Parent Authorization (To be completed by the parent or legal guardian.)
In accordance with the Family Educational Rights and Privacy Act (FERPA), I authorize the school to release state and national test scores for my student to the Riverside County Office of Education. I understand this information will only be used to consider the student for the Riverside County Seal of Multiliteracy. I give the Riverside County Office of Education permission to photograph and/or videotape my student for educational purposes. I give the Riverside County Office of Education permission to list the names of awardees on the Riverside County Office of Education website.Date:
Printed Parent Name:
Parent Signature:
Target World Languages to be Assessed (Language of proficiency other than English.)
Target languages assessed are dependent on availability of assessor.
1st Target World Language: / Dialect:2nd Target World Language: / Dialect:
Target Language Verification: Signature of Adult Proficient in 1st Target World Language:
Person verifying student proficiency may be a school official or community member but may NOT be a parent or relative of student.
I encourage and support this student to apply for the Riverside County Seal of Multiliteracy based on proficiency in the target world language. This student has clearly demonstrated a high level of proficiency in speaking, listening, reading, and writing.Date: / World language that you are verifying:
Printed Name: / Affiliation With Student:
Phone: / E-Mail:
Signature:
Target Language Verification: Signature of Adult Proficient in 2nd Target World Language (If applying for more than one world language.) Person verifying student proficiency may be a school official or community member but may NOT be a parent or relative of student.
I encourage and support this student to apply for the Riverside County Seal of Multiliteracy based on proficiency in the target world language. This student has clearly demonstrated a high level of proficiency in speaking, listening, reading, and writing.Date: / World language that you are verifying:
Printed Name: / Affiliation With Student:
Phone: / E-Mail:
Signature:
Form A (Revised 3.18.16 MS)