Application for Admission | 2026-2027
Thank you for your interest in the Mississippi Dyslexia Institute. This application is designed to help us understand your background, experience, and vocational aims as we shape a cohort of highly committed and mission-aligned students.
Section 1 | Personal Information
Name
*
First Name
Last Name
Email
*
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Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Communication Method
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Email
Phone
Text
Date of Birth
*
-
Month
-
Day
Year
Date
Section 2 | Professional Profile
Current Occupation/Role
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Employer/Organization
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Years of Relevant Experience
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Professional Areas of Interest (Check all that apply)
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Dyslexia Intervention
Certified Academic Language Therapist (CALT)
Literacy Leadership
Classroom Practice
Research
Other
Section 3 | Educational Background
Highest Degree Earned
*
Please Select
Bachelor's
Master's
Specialist
Doctorate
Other
Educational Background (Please list your academic history beginning with your most recent degree.)
*
Proof of Degree (Highest Level Obtained)
*
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Licensure/Certifications (If Any)
Section 4 | Resume/Experience
Resume or CV
*
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Section 5 | Statement of Purpose
In 500–800 words, explain why you are applying to the Mississippi Dyslexia Institute. Please address: Your motivation to pursue this opportunity, relevant personal or professional experiences, how MDI aligns with your goals, and how you hope to contribute to your community.
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0/800
Section 6 | Professional References
Please provide two professional references who can speak to your academic, instructional, or professional abilities.
References:
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Section 7 | Disclosures & Confirmation
Your responses help ensure that the Mississippi Dyslexia Institute maintains a safe, ethical, and trustworthy learning environment. Any affirmative response may require further explanation and documentation. All information is confidential and will be reviewed holistically.
Have you ever been placed on academic probation, suspended, or dismissed from an academic institution?
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Yes
No
If yes, please explain:
Have you ever been found responsible for academic misconduct (e.g., cheating, plagiarism)?
*
Yes
No
If yes, please explain:
Have you ever been disciplined, terminated, or asked to resign from a professional role?
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Yes
No
If yes, please explain:
Are you currently or have you ever been the subject of a professional or licensure-related complaint or investigation?
*
Yes
No
If yes, please explain:
Has your professional license ever been suspended, revoked, or placed under review?
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Yes
No
If yes, please explain:
Have you ever been convicted of a misdemeanor or felony?
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Yes
No
If yes, please explain:
Are there any pending charges or ongoing legal investigations involving you at this time?
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Yes
No
If yes, please explain:
Do you have any condition that could affect your ability to fully participate in program requirements?
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Yes
No
If yes, please explain:
Will you be requesting any accommodations at this time?
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Yes
No
If yes, please describe:
Note: Requests for accommodations do not influence admissions decisions.
The Mississippi Dyslexia Institute is committed to maintaining the highest standards of professionalism, integrity, and care. If admitted, I agree to uphold the following expectations:
To treat all students and colleagues with dignity, respect, and fairness
To maintain confidentiality and safeguard sensitive information
To follow the ethical guidelines governing literacy instruction and clinical practice
To conduct myself with honesty, humility, and accountability
To seek help when needed to ensure the highest quality of support for learners
To represent MDI with integrity in my professional practice
Applicant Signature
*
Section 8 | Application Fee & Submission
Your application is not considered complete until payment has been submitted. The fee supports admissions review, credential verification, and application processing. It is non-refundable, regardless of admissions outcome.
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Application Fee
The Mississippi Dyslexia Institute assesses a $50 non-refundable application fee to support admissions processing and credential verification. Your application is not considered complete until this payment has been submitted.
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