ACSA Clear Administrative Credential Program Application

ACSA Clear Administrative Credential Program Application

This application is for the two-year Clear Administrative Credential Program with the Association of California School Administrators. You will be asked to submit two documents as part of this application process. The first document is a Verification of Administrative Employment Form and the second document is a copy of your credential used to meet eligibility requirements. Contact the ACSA office at credentialing@acsa.org if you have questions or need assistance.
Non-Discrimination Information

No candidate will be discriminated against on the basis of race, color, religion, sex, marital status, national origin, ancestry, familiar status, disability, sexual orientation, pregnancy or pregnancy related condition in its employment practices. This policy of affording equal candidates access to all persons is in keeping with provisions of state and federal laws and regulations.
Candidate Personal Information
Name *

First Name Middle Name Last Name
Home Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Preferred Email Address *
example@example.com
Preferred Phone Number *
Please enter a valid phone number.
Local Program Information

The Local Program Coordinator provides advisement to candidates and matches candidates with a coach. Please select the local program coordinator closest to your employment. This list presents numerous districts. The final selection is ACSA programs’ and are applicable for areas not associated with another local program. Please contact credentialing@acsa.org if you have questions about local programs.
Select the Local Program for which you received advisement. *

Alhambra USD (Janet Lees) Anaheim UHSD (Dr. Scott Jensen) Garden Grove USD (Jesus Vazquez) Hacienda La Puente USD (Joanne Chan/Dr. Judy Fancher) San Bernardino City Unified School District (Mary Pierce) Whittier UHSD (Dr. Carlye Marousek) Contra Costa COE (Julie Dooley) L.E.A.D. (Leslie Anderson/Bill Faraghan) North Redwoods (Jennifer Fairbanks) Palmdale SD Consortium (Kathy Wehunt/Danny Kanga) Shasta SOE (Dr. Kimberlee McKenzie) Solano COE (Sandy Jessop) ACSA Inland Empire (Dr. Patricia Mark/Dr. Tracy Robinson) ACSA Northern CA (Dr. Tracy Robinson) ACSA Silicon Valley (Betsy Warren/Dr. George Manthey) ACSA Southern CA (Linda Peralta)
I have contacted my Local Program Coordinator? *

Yes No
For which cohort of the ACSA CACP are you applying? *

Fall 2021-2023 Readmission from a Leave of Absence Transferring from another program for year 2 only
Education
Please select the your highest degree that you have achieved. *

Bachelor's Degree Master's Degree Doctoral Degree
Credential Preparation Information

The information provided in this section is necessary to verify eligibility for the ACSA Clear Administrative Credential Program. You must have a Preliminary Administrative Services Credential, a Certificate of Eligibility or a Variable Term Waiver.
Select the preparation route you completed to establish your Preliminary Administrative Services Credential. *

Completed a University/College Program Completed a County Office of Education or District Program Passed CPACE Completed an Internship Prepared out of the state of California Variable Term Waiver
Provide the Preliminary Administrative Services Credential or Certificate of Eligibility document from the California Commission on Teacher Credentialing. *

Cancel of
Employment Information
Title of Employment Position *
Position Start Date *

Month Day Year
Date
Work Email Address *
example@example.com
Work Phone Number *
Please enter a valid phone number.
District, County or LEA of Employment *
School or Site Name *
School/Site Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County of Employment *
Upload Verification of Administrative Employment Form Signed by your employer. Below is a link to the Verification of Administrative Employment form. *

Cancel of
Verification of Administrative Employment: https://www.acsa.org/application/files/6616/1671/2097/Verification_of_Admin_Employment.pdf
School/Site Demographic Information

This information assists local program coordinators in finding an appropriate coach match.
What is the setting of your school site of employment? *

General School Site Central Office County Office of Education Charter Private Other
Which student population is serviced at your school or site of employment? *

Primary/Elementary Middle School High School Alternative Education Adult Education Special Education Program/Department Other
What is the student population size of the school or site? *

Less than 100 100-250 251-500 501-1000 1001-2000 More than 2000
Self Reported Data

The following questions are self reported data per the reporting requirement in Assembly Bill 677 and SB 179.
Gender *

Female Male Nonbinary Prefer not to state gender
Sexual Orientation *

Heterosexual/Straight Gay or Lesbian Bisexual Not Sure Decline to state sexual orientation Other
Ethnicity *

American Indian or Native Alaskan Asian (Chinese, Japanese, Korean, Vietnamese, Asian Indian, Laotian, Cambodian, Filipino, Hmong) Black or African American Hispanic/Latinx (of any race) Native Hawaiian or Pacific Islander (Guamanian, Samoan, Tahitian) White Two or more races Decline to state race/ethnicity
ACSA Program Fees/Coaching Service Fees

ACSA CACP program fees are $1,000.00 per year for the two years. Coaching Service Fees can be up to $4,000.00 per year for two years, depending on your local program. Please consult with your program coordinator for Coaching fee information.
To the best of you knowledge at this time, who will be fiscally responsible for you ACSA CACP Program fess of $1,000.00 per year? *

Myself My Employer Other
To the best of your knowledge at this time, who will be fiscally responsible for your Coaching Services Fees of up to $4,000 per year (depending on your Local Program)? *

Myself My Employer Other
Are you a member of ACSA? *

Yes No
Candidate Commitment Application Completion
By signing, I acknowledge ASCA is a two-year induction program and admittance to the program may be granted after all documents are received and reviewed by a local program coordinator and the ACSA program director. I understand the program fees are $1,000.00 per year for a total of $2,000.00 and coaching fess are determined by each local program and may differ from program to program. *

Clear
Should be Empty:

ACSA Clear Administrative Credential Program Application

Non-Discrimination Information

Candidate Personal Information

Local Program Information

Education

Credential Preparation Information

Employment Information

School/Site Demographic Information

Self Reported Data

ACSA Program Fees/Coaching Service Fees

Candidate Commitment Application Completion