ReadOregon Program Application Form

formerly known as CREADE
Collaborative Reading Education And Distance Education

ReadOregon Application

IMPORTANT: Information gathered below is necessary for management of the ReadOregon programs. One-time completion of this form is required in order to enroll in ReadOregon programs and/or receive tuition assistance for courses.

Please submit a second application only if important personal information changes, e.g., new address or phone number, different school, updated license status, changing home institution. (Indicate that this is an updated application in the comments box.)


Your Name
Mailing Address
City, State, Zip
Email
Home Phone
Work Phone
Fax
Gender	female male
Age	20-29 30-39 40-49 50+
Highest Degree	Associate Bachelor's Master's Doctorate
Ethnic Identity (optional) Please fill in ethnic group or tribal affiliation in space provided.	White, European American Black, African American Hispanic American Asian American Pacific Islander American Indian/Alaskan Native Middle Eastern North African Decline to respond
Teaching License Status	Oregon Basic or Standard (prior to 1999) license Oregon Transitional license Oregon Professional Technical license Oregon Initial license Oregon Continuing license Out-of-state license from In process; preservice Other (explain)
License Authorization Level	Early Childhood Elementary Middle School High School
Have you passed the PRAXIS II Reading Specialist exam?	No Yes
Endorsement Areas
Job Status	Full-time teacher working in Oregon Substitute teacher working in Oregon Part-time teacher working in Oregon Instructional Assistant working in Oregon Administrator working in Oregon Have teaching license, but not teaching Student Other (explain)
Name of your school
City/town of your school
Years of teaching preK-12
Name of institution and program if enrolled in master's or teacher prep program
ReadOregon program in which you are interested	24-credit endorsement 12-credit classroom literacy certificate courses/modules (for professional development)
University you want as your "home institution" For academic advising and issuing endorsement or certificate You may choose any of the 5 universities as your "home" regardless of where you live.	Eastern Oregon University Oregon State University Portland State University Southern Oregon University Western Oregon University If you are enrolled in a master's program, choose that university as your home institution. They will advise you which ReadOregon courses may be able to count toward your degree.
How did you hear about ReadOregon?	At school or from principal CREADE or ReadOregon flyer Former CREADE website ReadOregon.org website College/university professor Other (explain)
Does your district provide funds for professional development?	No Yes
Could you participate in ReadOregon courses without tuition assistance? (either district or grant-funded)	No Yes
Why are you interested in the ReadOregon programs?
Other Questions or Comments
	Read Oregon has been receiving a large number of spam form submissions. To help ensure that your application is not accidentally considered spam, please answer the following question. We're sorry for the inconvenience. What does the 'R' in CREADE stand for?

Thank you for filling out the ReadOregon program application.
Please print this form before submitting if you wish to retain a copy.

Your information will be sent to the ReadOregon office and will be forwarded to your chosen "home institution."

READ OREGON is a consortium of five Colleges/Schools of Education of the Oregon University System
in cooperation with their respective Departments of Distance and Continuing Education.

Eastern Oregon University Oregon State University Portland State University
Southern Oregon University Western Oregon University