Application For Washington State Conditional Certificate Page 11
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12OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION
Professional Certification
Old Capitol Building, PO BOX 47200
NOTE: THIS FORM MAY BE
OLYMPIA WA 98504-7200
DUPLICATED. A
(360) 725-6400 TTY (360) 664-3631
SEPARATE FORM IS
Web Site:
REQUIRED FOR
E-Mail: cert@k12.wa.us
EACH DISTRICT IN
DISTRICT REQUEST FOR
WHICH THE
APPLICANT WILL
CONDITIONAL CERTIFICATE
SERVE.
INFORMATION TO BE GIVEN BY DISTRICT SUPERINTENDENT OR PERSONNEL DIRECTOR ONLY
APPLICANT NAME
SPECIFIC ASSIGNMENT IN WHICH THE APPLICANT WILL BE SERVING
DISTRICT
THE ASSIGNMENT WILL BEGIN
TERMINATE
ADDRESS
TELEPHONE NUMBER
(
)
CITY/STATE/ZIP
E-MAIL
Is this a renewal of the conditional certificate?
NO
YES
If yes, has the applicant completed 60 clock hours since the issuance of the most recent certificate?
YES
NO
I confirm that the following is true:
•
The applicant meets the following condition(s) for application (check any that apply):
The applicant is highly qualified and experienced in the subject matter to be taught and has unusual distinction or
exceptional talent demonstrated through public records of accomplishments and/or awards.
No person with regular teacher certification in the endorsement area is available as verified by the district or educational
service district superintendent or approved private school administrator, or circumstances warrant consideration of
issuance of a conditional certificate.
Applicant is qualified to instruct in the traffic safety program as a paraeducator pursuant to WAC 392-153-020(2)(3).
Applicant is assigned instructional responsibility for intramural/interscholastic activities which are part of the district
approved program.
Applicant possesses a state of Washington license as a registered nurse but does not have a bachelor’s degree in nursing.
Applicant has completed a baccalaureate degree in speech-language pathology or audiology.
Applicant for special education possesses a baccalaureate degree, is enrolled in a residency teacher program in special
education and (for renewals) is making satisfactory progress.
Applicant for a second conditional school speech language pathologist or audiologist certificate is enrolled and
making satisfactory progress in a master's degree program for SLP or audiology.
•
The district has determined the applicant is competent on the following basis (attach additional sheet if necessary):
•
The individual is being certificated for a limited assignment and responsibility in a specified activity/field.
•
The local school board has authorized submission of the application. (Required only for classroom instruction assignment.)
For individuals providing classroom instruction, the following criteria will be met:
•
The individual will receive the direct assistance of a school district mentor. (Endorsed in special education for special
education applicants.)
•
The individual will be delegated primary responsibility for planning, conducting, and evaluating instructional activities and will
not be serving in a paraeducator role which would not require certification.
•
Within the first 60 working days, personnel so certificated will complete 60 clock hours (six quarter hours or four
semester hours) of course work in pedagogy and child/adolescent development appropriate to the assigned grade
level(s) as approved by the employing school district.
•
Personnel so certificated will be oriented and prepared for the specific assignment and will be apprised of any legal liability, the
responsibilities of a professional educator, the lines of authority, and the duration of the assignment. A written plan of assistance
will be developed in cooperation with the person to be employed within 20 working days from the commencement of the
assignment. This condition is also required for school nurses serving under the conditional certificate.
SIGNATURE OF SUPERINTENDENT/PERSONNEL DIRECTOR
PRINTED NAME AND TITLE
DATE
FORM SPI/CERT 4025E (Rev. 9/15)
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