Masters of Arts in Special Education
Program Application
Fall 2008
PLEASE PRINT CLEARLY
Name
Last First Middle Maiden/Former
Address Home Phone ( )
Street Unit/Space Include Area Code
Work Phone ( ) City State Zip Include Area Code
E-mail Address: please print exactly (lower/UPPER case)
Social Security # - - Date of Birth / /
Gender: M □ F □ Ethnic Identity (Optional)
(Gathered for state reporting purposes only)
University granting Bachelor’s Degree:
Academic Major:
Education Employment Experience: Please complete the following starting with your current position.
Name of School Name of District Years of Service Assignment
______
______
______
Please add an additional page if needed.
1. University Graduate Application
□ Application has been submitted online at www.csumentor.edu along with the $55.00 application fee.
Arrange to have one set of official transcripts mailed directly to the CSU Channel Islands Office of Admissions from each college or university attended, including your degree posted and date awarded. CSUCI students do not need to submit transcripts previously submitted to CSUCI Admissions Office.
Please list ALL colleges and universities attended. A cumulative grade point average of 3.0 in Post Baccalaureate or graduate work is required.
Name of Institution / Date of Attendance / Degree Received2. Program Application
□ Receipt for application fee of $25.00 from the cashier’s office attached.
The Credential Program application fee of $25.00 will need to be paid at the Cashier’s Office located on the first floor of the Professional Building in the Enrollment Center, prior to submitting your application to the Credential Office
3. CBEST Exam
□ CBEST passed on ______and copy of score report attached.
4. Copy of a valid California credential.
□ Copy of Valid Preliminary Education Specialist Credential (not Certificate of Eligibility)
5. Writing Sample
□ Attached is a written statement of purpose (500-600 word essay). Your essay should include personal and professional reflection on personal goals and developing the knowledge and skills to achieve these goals. (A typed copy using 12 point size is recommended)
6. Two Letters of Recommendation from professional who are knowledgeable of your professional work at least one of whom is your current school administrator. (Use the forms included).
□ Attached are two recommendation forms in separate, sealed and signed envelopes.
7. Verification of Employment (use the form included)
□ Attached is the Verification of Employment form (CL7777.1) verifying two years of full time
teaching experience as an Education Specialist teacher (substitute or part time experience does not apply).
An interview for qualified candidates. Information regarding interviews will be mailed to you only when your application is complete and your file has been evaluated. Students are not eligible for financial aid until admitted to the Masters Program. In order to be admitted to the Masters Program the application must be completed, all requirements met including a successful interview.
Recommendation for Admission
Masters of Arts in Education Program
¨ Educational Leadership ¨ Special Education
The applicant named below is seeking admission to the Masters of Arts in Education Program at CSU Channel Islands. CSU Channel Islands seeks to admit educators who a have strong teaching background (minimum of three years) and who demonstrate the personal and professional potential to become highly successful school leaders committed to improving the learning environment for all students. Academic skills, standards of moral and ethical behavior, and a commitment to work on behalf of all children are essential prerequisites for success.
Please give us your assessment of the applicant based on these criteria in this confidential recommendation form. Please complete both sides of this form: written reference on the front and rating form and brief comments on the back. Thank you.
NAME OF APPLICANT______
Name of Reference:______Date:______
Signature: ______Position______
Address:______
______Phone:______
*Please place this completed form in a sealed and signed envelope and return it to the applicant.
PLEASE CIRCLE THE NUMBER FOR EACH ITEM THAT BEST INDICATES YOUR ASSESSMENT OF THE APPLICANT. THE SCALE RANGES FROM 5 (HIGH—OUTSTANDING ABILITY) TO 1 (DEFINITE LIMITATION).
HIGH LOW NOT
OBSERVED
1. Speaks effectively 5 4 3 2 1 ____
2 . Writes effectively 5 4 3 2 1 ____
Comments:
3. Works well with colleagues 5 4 3 2 1 ____
4. Works well with persons 5 4 3 2 1 ____
from diverse backgrounds
5. Relates well with 5 4 3 2 1 ____
students
6. Relates well with 5 4 3 2 1 ____
families of students
Comments
7. Teaches effectively 5 4 3 2 1 ____
8. Works independently 5 4 3 2 1 ____
9. Demonstrates intellectual 5 4 4 2 1 ____
curiosity
10. Works conscientiously 5 4 3 2 1 ____
Comments
11. Handles stress well 5 4 3 2 1 ____
12. Adheres to ethical 5 4 3 2 1 ____
standards of behavior
13. Accepts 5 4 3 2 1 ____
extra responsibility
14. Shows ability to 5 4 3 2 1 ____
accept feedback
Comments
15. Shows leadership 5 4 3 2 1 ____
potential
Final Comments
5
California State University Channel Islands Teaching Credential Program One University Drive, Camarillo, CA 93012 (805) 437-8953