Practicum Application

Prerequisite: 40-Hour Basic Orton-Gillingham

First Name*

Last Name*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Best phone number to reach me at*

Email*

Preferred Practicum Location*

Dyslexia institute of Indiana Office Video

Availability*

Availability
	Morning	Afternoon	Evening
Monday	Availability: Monday (Morning)	Monday (Afternoon)	Monday (Evening)
Tuesday	Tuesday (Morning)	Tuesday (Afternoon)	Tuesday (Evening)
Wednesday	Wednesday (Morning)	Wednesday (Afternoon)	Wednesday (Evening)
Thursday	Thursday (Morning)	Thursday (Afternoon)	Thursday (Evening)

Are you a DII Instructor?

Yes No

Are you a classroom teacher? If so, where?*

How did you hear about DII?*

What type of degree(s) do you have?*

Are you interested in becoming a tutor for DII? If so, why?*

Do you have any additional comments?

Please call me! I would like to pay by credit card.

Yes

I will mail a check to DII.

Yes

Please invoice my school/district.

Yes

School/District Name

School/District Contact Person

Contact Person Email (this is where your invoice will be sent)

Billing Address

Address Line 1

Address Line 2

City

State

ZIP Code

Practicum participants must provide their own practicum student. The student must be pre approved through your practicum supervisor.

Dii's Director of Programs and Training will be in touch soon to place you with your practicum supervisor.

Cost of the practicum: $950

Payment must be received before you begin your practicum.