10700 SW Beaverton Hillsdale Hwy, Suite 470-2
Beaverton, Oregon 97005 – (503) 924-3157
info@languageskillstherapy.org

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Driver's License

State and number (information required for background check)

Date of Birth

Information required for background check

YYYY

EDUCATION

Undergraduate Institution/Degree/Year

Postgraduate Institution/Degree/Year

Have you held or do you currently hold a teaching certificate?

If yes, in what state(s) is it valid?

Have you had special education training?

Orton-Gillingham (O-G) Training

Have you received O-G /multisensory training from any of the following organizations:

Academic Language Therapy Association (ALTA)

Orton Gillingham Academy (OGA)

International Dyslexia Association (IDA)

International Multisensory Structural Language Education Council (IMSLEC)

Wilson

If yes, indicate any credential from the organization.

What is your experience with or knowledge of students with dyslexia/attention deficit disorder and related learning problems?

Are you a member of the International Dyslexia Association or similar organization?

REFERENCES

Please provide the names, addresses and telephone numbers of three people who can serve as professional references.

PLEASE ATTACH A CURRENT CV OR RESUME TO YOUR COMPLETED APPLICATION.

Please email us or include a link to your CV using URL to your Dropbox, Google Drive, or Linkedin.