ENROLLMENT FORM

Master's Level Speech-Language Pathologist Stipend for School-Based Placements

Directions: Complete the following information to enroll the LEA and the master's level speech-language graduate student(s) into the "Stipend for School-Based SLP Graduate Extern" program. Once all forms from the LEA are submitted, a statement of agreement will be sent to the LEA's grant contact listed below.

I. Local Education Agency Information

Name of Local Education Agency *

Street Address *

Address Line 2

City *

Zip Code *

Type of LEA *

Intermediate Unit in which the LEA is a member district *

Number of spring 2025 externs *

II. Grant Contact Information

Name of LEA Contact: *

Work Email Address *

Work Phone *