<p> Massachusetts Early Intervention COMPETENCY EDUCATION CREDIT ASSIGNMENT APPLICATION</p><p>Instructor Profile Form</p><p>Instructor Name: </p><p>Educational Offering: Educational Background College or University Degree Date Rec’d</p><p>Early Intervention Experience Massachusetts CEIS #: Other certificates/licenses</p><p>Supervision and Training Experience (including team teaching and mentoring)</p><p>Qualifications (experience and training) for presenting this topic:</p><p>Other Related Experience (e.g., parent of a child with special needs, community service, volunteer work, etc)</p><p>Competency Education Credit -- Application/Instructor Profile Page 1 of 1 Early Intervention Training Center, 2005</p>