MIDDLE GEORGIA RESA
ALTERNATIVE PREPARATION FOR EDUCATIONAL
LEADERSHIP PROGRAM
TIER I: EDUCATOR CANDIDATE APPLICATION
Candidates applying for the Alternative Preparation for Educational Leadership Program must
complete all fields of the Candidate Application.
Candidate Information
Last Name First Name Middle Initial
Street Address
City State Zip
Home Phone Work Phone Cell Phone
Last 4 digits of your Social Security Number
Email Address
Current position and District
School/Organization
Years Experience
in Education
Highest Degree Held:
Awarding College/University:
GA Teaching Certificate #:
Expiration Date:
Additional Information
Endorsements Held:
☐ Teacher Leadership
☐ Coaching
☐ Teacher Support and Coaching
Have you received National Board
Certification?
_____ Yes
______No
Leadership Experience
(attach additional information as needed)
Leadership Positions Held School/District Years in this Position Related Training
1.
2.
Page 1 of 8
MIDDLE GEORGIA RESA
ALTERNATIVE PREPARATION FOR EDUCATIONAL
LEADERSHIP PROGRAM
TIER I: EDUCATOR CANDIDATE APPLICATION
Assurances
District Assurance
This is to certify that __________________________________has received an offer of employment from
________________________________ School District and is being recommended for admission into the
Alternative Preparation for Educational Leadership Program. If selected for the program this
candidate will be available to work in a leadership position within our school and/or district
one-half day or more each day.
Printed Name of Human Resources Director: ___________________________________________________________
Signature of Human Resources Director: ________________________________________________________________
Contact Information:
● Email Address: ______________________________________________
● Telephone Contact: _________________________________________
I prefer to be contacted by: _______email _______ telephone ______other (specify)
Superintendent’s Signature: ______________________________________________________________________________
School Assurance
It is my understanding that __________________________________________ has received an offer of employment
from ________________________________ School District and is being recommended for admission into the
Alternative Preparation for Educational Leadership Program. If selected for the program this
candidate will be available to work in a leadership position within our school and/or district one-half
day or more each day.
Printed Name of Principal/Immediate Supervisor: ______________________________________________________
Signature of Principal/Immediate Supervisor: ___________________________________________________________
Contact Information:
● Email Address: ______________________________________________
● Telephone Contact: _________________________________________
I prefer to be contacted by: _______email _______ telephone ______other (specify)
Page 2 of 8
Resume
Attach your professional resume including the following information:
1. Universities/colleges attended, degrees earned, GPA
2. Educator work experience including organization, position, location, supervisor, dates
3. Leadership experience including organization, position, location, supervisor, dates
4. Evidence of performance such as newsletters, websites, projects, conferences etc.
5. Other professional experience
6. Academic honors/awards earned
7. Names, addresses, phone and email of three professional supervisor references
Transcripts
Include sealed official transcripts for all universities/colleges attended.
Evidence of Leadership Experience
Submit evidence of successful teacher leadership experience. This should specifically include
evidence of your experience in engaging colleagues in professional learning opportunities.
This may include (but is not limited to) experiences such as leading grade/department level
meetings, leading professional learning communities, presentations at school, district, state or
national meetings, etc.
Evidence of Successful Teaching
Submit evidence that you have been a successful teacher. This should include specific results of
improved student achievement that resulted from your contribution. Thoroughly describe what
you did to achieve these results.
Signature and Release of Information
I understand that a false statement, omission or misrepresentation on any part of my application or
materials submitted during the application process is grounds for being denied eligibility to or
dismissal from Middle Georgia RESA’s Alternative Preparation for Educational Leadership program.
Signature: __________________________________________________________________________ Date: _________________
Page 3 of 8
Program Cost and Payment
The cost for the twelve-month Tier I program is $6,000 for candidates within the Middle GA RESA service
area and $6850 for those not within the Middle GA RESA service area. These charges include all training
(TKES/LKES) and materials as well as expenses incurred by MGRESA coaches for travel to districts.
Candidates requiring extended program time for completion will be charged on a sliding scale.
APEL payments will be payroll deducted monthly through your system of employment. The appropriate
payroll deduction form (attached) must be completed and submitted to the Middle Georgia RESA office
before official acceptance into the APEL program.
Submission of Applications
Submit Completed Applications to:
Address:
Middle Georgia RESA
Attn: Christina Pearson
Central GA Technical College – WR Campus
Building B, Room 228
80 Cohen Walker Drive
Warner Robins, GA 31088
Email: cpearson@mgresa.us
Phone: 478 988-7170
Fax: 478 988-7176
Applications must be received by April 15, 2022
Additional Information
Dr. Robin Smith
Professional Learning Director
rsmith@mgresa.us
Page 4 of 8
MGRESA APEL Program Candidate Agreement
In order to maintain the structure and integrity, as well as, implement the program with fidelity, participants are
responsible to know, understand, and do the following things:
Candidate Name: Date:
Please acknowledge your understanding and agreement by initialing the criteria to be followed
throughout the program or program.
Initials
1. I understand that as an educator I will display appropriate professional behavior as outlined in the
MGRESA APEL Candidate Dispositions, which includes the submission of original course work.
2. I understand that the Georgia Professional Standards Commission (GAPSC) has recognized MGRESA
as an approved Education Preparation Provider (EPP) and requires instructors and candidates to
adhere to the guidelines of the program. Assignment criteria are non-negotiable and must be
completed as assigned.
3. I understand that the APEL program has a specially designed program of work developed to help
obtain the enhancement of the program standards; and that I will complete ALL online or in class
course work (assignments, assessments, forums, etc). I understand that I will upload my work to
Moodle for assessment.
4. I understand that course content requirements and assignments will be completed by due dates
to mastery as designated by the program and indicated in the course syllabus and/or scoring
guides. I understand that I am required to re-accomplish and re- submit any substandard work.
5. I understand that failure to adhere to the MGRESA Program guidelines and standards for mastery
will result in failure to receive credit for the course and a non-recommendation for the award of
the program.
6. I understand that the APEL program has specific face-to-face meetings and that I am required to
attend ALL onsite course meetings and seminars. The dates are provided prior to beginning the
program. If an emergency arises which prevents attendance, the candidate must contact the APEL
Program Manager to request permission. Failure to attend meetings may result in program dismissal.
7. I understand that I am expected to complete the course assignments and specially designed work
identified by my Candidate Support Team (CST). The work will be submitted by the assigned due dates. I
am responsible for communicating and seeking any deviation from the due dates provided. Supporting
documents, such as an FMLA form, must be submitted with a request for extension.
9. I understand that if I fall two or more weeks behind, my instructor will notify the MGRESA Program
Development Coordinator. As a good steward of school district funds, the Program Development
Coordinator is required to notify the system when candidates are not progressing.
10. I understand that I am responsible for procuring course materials. Outstanding fees must be paid for
all prior to the recommendation of program award.
Candidate Signature Date
Page 5 of 8
MIDDLE GEORGIA RESA
ALTERNATIVE PREPARATION FOR EDUCATIONAL
LEADERSHIP PROGRAM
TIER I: EDUCATOR CANDIDATE APPLICATION
APEL TIER I APPLICATION PACKAGE CHECKLIST
Please be sure all of the following required documents are complete and included in your
application package.
_______ Application - including all required signatures for District and School Assurances
_______ Resume
_______ Official Transcripts
In order to be considered official, transcripts must come directly from the college
or university and be in a sealed unopened envelope. Transcripts may also be
submitted to us electronically, directly from the college or university. If sending
electronically, please have them emailed to:
Christina Pearson at cpearson@mgresa.us
_______ Evidence of Leadership Experience (see page 3)
_______ Evidence of Successful Teaching (see page 3)
_______ MGRESA APEL Candidate Agreement Form
_______ Copy of your Georgia Educator Certificate
Please note:
The following Payroll Deduction Agreement is required upon acceptance into the program.
Please choose one form based on whether you are employed by a member or nonmember
system.
Page 6 of 8
MIDDLE GEORGIA RESA MEMBER SYSTEM
PAYROLL DEDUCTION AUTHORIZATION
(Bibb, Crawford, Houston, Jasper, Jones, Monroe, Peach, Twiggs)
I, ______________________ (Employee Name),_______________(Employee ID #), authorize
the deduction of $461.54 per month for 13 months from my payroll check by the
_____________ (District Name) County School District payroll office. The deduction will begin
May 2022 and continue through May 2023. This deduction is being made to care for the cost
of the MGRESA Alternative Preparation for Educational Leadership (APEL), at a total cost of
$6,000.00
If necessary, Second or Third Year Program fees will be handled through payroll deduction
during the subsequent school year(s). A new Payroll Deduction Authorization Form will be
completed for these fees.
Should I leave the employment of ___________ (District Name) County Schools prior to
May 2022, I understand that the remaining balance due will be deducted from my final check.
______________________________ _____________
Candidate Signature Date
_______________________________________
Printed Name, Title
Human Resources/ Payroll Representative
________________________________________ _________________
Signature, Human Resources/ Payroll Representative Date
*** Candidate will complete and submit this form to his/her school system HR/Payroll Dept.
***HR/Payroll will return the completed form to Christina Pearson (cpear[email protected])
Contact Person: Christina Pearson
Administrative Assistant, PL
Middle Georgia RESA
80 Cohen Walker Drive
Warner Robins, GA 31088
PH: 478-988-7163
FAX: 478-988-7176
Page 7 of 8
MIDDLE GEORGIA RESA
NON-MEMBER SYSTEM
PAYROLL DEDUCTION AUTHORIZATION
I,______________________ (Employee Name),_______________(Employee ID #),
authorize the deduction of $526.93 per month for 13 months from my payroll check by the
_____________ (District Name) County School District payroll office. The deduction will
begin May 2022 and continue through May 2023. This deduction is being made to care for
the cost of the MGRESA Alternative Preparation for Educational Leadership (APEL), at a
total cost of $6,850.00
If necessary, Second or Third Year Program fees will be handled through payroll deduction
during the subsequent school year(s). A new Payroll Deduction Authorization Form will be
completed for these fees.
Should I leave the employment of ___________ (District Name) County Schools prior to
May 2022, I understand that the remaining balance due will be deducted from my final check.
______________________________ _____________
Candidate Signature Date
________________________________________
Printed Name, Title
Human Resources/ Payroll Representative
________________________________________ _________________
Signature, Human Resources/ Payroll Representative Date
*** Candidate will complete and submit this form to his/her school system HR/Payroll Dept.
***HR/Payroll will return the completed form to Christina Pearson (cpear[email protected])
Contact Person: Christina Pearson
Administrative Assistant, PL
Middle Georgia RESA
80 Cohen Walker Drive
Warner Robins, GA 31088
PH: 478-988-7163
FAX: 478-988-7176
Page 8 of 8
