LAST 4 OF SOCIAL SECURITY NUMBER: *

LAST NAME: *

FIRST NAME: *

MIDDLE NAME:

PREFERRED NAME: *

MAIDEN NAME:

STREET ADDRESS: *

CITY: *

STATE: PLEASE SELECT YOUR STATE OTHER ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING OUTSIDE THE US *

ZIP CODE: *

COUNTRY: *

WORK PHONE:

HOME PHONE:

CELL PHONE: *

FAX:

EMAIL: *

DATE OF BIRTH: *

CITIZENSHIP STATUS: U.S. Citizen
Permanent Resident
Other Citizenship
*

GENDER: Female Male *

Upon completion of all AMS requirements, adult learners are recommended for an AMS Montessori Certificate/Credential. Please indicate how you prefer your name to appear on your certificate/credential, if applicable:

Where did you hear about CME|NY?

Proficiency in the English language is required for admission into our programs, as classes are conducted in English and written work must be submitted in English. Adult Learners must be able to speak, understand, read, and write English to succeed in our courses. Proficiency in this requirement is determined during the application process. Adult Learners who do not meet this requirement will not be accepted into the program. Are you proficient in English?

While we require English proficiency, we do welcome a cultural and ethnically diverse community of Teachers and Adult Learners. If you are fluent in other languages, please let us know what other languages you speak:

Is there anything about your learning style that would enable us to better assist you during the course?

I am applying at the request of the following school where I am employed:

The school will be responsible for paying for my tuition and other fees. YES NO

Please contact your educational institution to request official transcripts to be forwarded to our office, as the are required for admisssion.  If your transcripts are from an educational institution that is located outside the United States, they must be evaluated by a U.S. evaluation service.  We suggest you contact World Education Services.

For candidates without a Bachelor's degree seeking an I/T or EC Associate Credential, please be aware that as local and state regulations for teaching qualifications vary, it is the Adult Learner's responsibility to confirm his/her required qualifications for employment in the state/city where s/he will be seeking employment.

SCHOOL:

POSITION:

FROM:

TO:

PREVIOUS SCHOOL:

POSITION:

FROM:

TO:

OTHER EXPERIENCE WORKING WITH CHILDREN

TEACHING CERTIFICATE (Please send a copy to our office):

Three current letters of recommendation are required for admission to our program.  These should be written specifically for admission to our program.  At least two of these must be professional.  Please list the names and information for the three people who will be submitting recommendations to us on your behalf:

PRACTICUM (INTERNSHIP SITE) SCHOOL NAME

SUPERVISING TEACHER

STREET:

STATE: ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING

ZIP CODE:

PHONE NUMBER:

FAX:

EMAIL ADDRESS:

SCHOOL DIRECTOR:

SCHOOL AFFILIATION: AMS AMI

AMS MEMBER SCHOOL #

EXPIRATION DATE

AMI AMS AMI

OTHER:

This school has served as a Practicum site for other CME|NY adult learners.

I do not have arrangements for a Practicum (internship) site. If you do not have a practicum site, please visit the AMS website www.amshq.org to view school listings for possible practicum school locations.

Do you need accommodations at the CNR dormrooms? YES NO

CANCELLATION BY APPLICANT: The applicant may canel this contract and receive a full refund of all monies paid to date if cancellation is made in writing and mailed to Melanie Pappas, CME/NY, Mamaroneck Avenue, White Plains, NY 10605, postmarked within five (5) business days, after the date of the signature on this application.

REFUND POLICY: If an Adult Learner withdraws from the program one month prior to the program starting date, 100% tuition (less registration fee) will be refunded.  After the start of the program, allowable refund percentages are computed from the date of official withdrawal, not from the time when the Adult Learner ceases attending classes.  Please see our Refund Policy on-line at our Website.  The Adult Learner is required to withdraw officially by submitting a written letter of intent to the Executive Director and his/her Level Coordinator.

CANCELLATION OF PROGRAM: CME|NY reserves the right to cancel any program prio to its start date due to lack of enrollment.  In the event of such cancellation, paid fees, deposits, and tuitions will be refunded.