NILD Educational Therapy Course Application

Applicant Information

Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

Current Job Position*

Educational Background

College/University*

Major*

Degree Held*

Date of Completion*

Do you have more education to record?*

Yes
No

College/University

Major

Degree Held

Date of Completion

College/University

Major

Degree Held

Date of Completion

Do you have teaching experience? (Home Education or School)*

Yes
No

Teaching Experience

School Name

School Administrator Name

First Last

School Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

School Phone

Calendar Years

Grade Level

JK/SK
Elementary
Secondary

Do you have more educational experience to record?*

Yes
No

School Name

School Administrator Name

First Last

School Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

School Phone

Calendar Years

Grade Level

JK/SK
Elementary
Secondary

How many years of teaching experience do you have?*

1 - 5 years
6 - 10 years
11 - 20 years
20+ years

Please select the statements that are most accurate for you:*

I am a classroom teacher in a school that has an established NILD Program.
I am a classroom teacher desiring to implement the NILD Program.
I am a private practice therapist.
I am a home educator.

School and Program Director Name where NILD program is established*

School and Administrator Name where you desire to to implement the NILD program*

NILD Training

Select the NILD Educational Therapy Course you are applying for*

Level I
Level II
Level III

NILD Level I - Month & Year Achieved*

NILD Level I - Course Location*

NILD Level I - Course Instructor*

First Last

NILD Level II - Month & Year Achieved*

NILD Level II - Course Location*

NILD Level II - Course Instructor*

First Last

Please check off the boxes below to indicate that you have completed all the admission requirements for Level II:*

I have completed the Level I course (within the last 3 years)
I have completed 80 student contact hours
I have observed a live therapy session (Level II) and/or viewed one posted on the NILD Canada website
I have recorded a therapy session of mine and submitted it to info@nildcanada.org for evaluation
I have attended an NILD Conference and/or workshop this year
I have maintained my registration and licensing with NILD Canada
I have completed the WJIV training course
I have completed all the job-embedded coaching sessions
I have completed the Gray Matter Literacy training after May 2022

Please check off the boxes below to indicate that you have completed the admission requirements for Level III:*

I have completed Level I and II (within the last 3 years)
I have completed 160 student contact hours between Level II and III
I have observed a live therapy session (Level III) and/or viewed one posted on the NILD Canada website
I have attended an NILD Conference and/or workshop this year
I have maintained my registration and licensing with NILD Canada
I have completed the WJIV training course
I have completed the Gray Matter Literacy training after May 2022

NILD Educational Therapy Experience

Name of School or Practice*

If you are a private therapist, please enter your own name.

Number of students since you completed Level I*

Name of School or Practice*

If you are a private therapist, please enter your own name.

Number of students since you completed Level II*

Final Questions 🙂

How did you first learn about NILD's courses?*

Check all that apply:

Website
Referral
Info Session
Conference
Facebook
Email from NILD Canada

Why did you choose to apply for the NILD Educational Therapy course? Where and how do you plan to use this new knowledge and methodology?*

As part of the course, you will be working alongside your classmates in various activities and group work. To support collaboration and communication, we are asking for your permission to share your email address and/or contact information with the entire Level I class.*

Yes, I give permission to share my email address/contact information with the entire Level I class.
No, I do not give permission to share my email address/contact information with the class.

I hereby give permission for NILD Canada to take and use photos of me for the purpose of marketing and promotion.*

Yes
No

I affirm that, to the best of my knowledge all of the above information is complete and accurate and I agree to the policies and procedures of NILD Canada.*

Please review our Privacy Policy as well as our Refund Policy.

Yes
No

Do you have any special concerns?

Course Application

Applicant Information

Educational Background

Teaching Experience

NILD Training

NILD Educational Therapy Experience

Final Questions 🙂

You have Successfully Subscribed!