Please check the program(s) you are applying for

:

❑ Infant – Toddler
❑ Spring ❑ Summer

❑ Elementary I ❑ Elementary I – II ❑ Elementary II (must have completed Elementary I) ❑ Administration
❑ Model I (for those without Montessori credential) ❑ Model II (for those with a Montessori credential) ❑ Model III (for those seeking a teacher and administration credential – dual certification)

❑ Early Childhood
❑ Spring ❑ Summer

Personal Information
Last Name Preferred First Name Street Address City Phone (Day) State (Evening) First Name Maiden Name Apartment Number Zip Code Cellphone Number Country Email Middle Initial AMS Number

Educational Background (Please list additional institutions on a separate page)
High School City and State Graduation Date

College Major

City and State Degree/Credits Completed

Dates Attended Date Degree Received

College Major

City and State Degree/Credits Completed

Dates Attended Date Degree Received

Post-Graduate Degree(s)

Degree/Credits Completed

Dates Attended/Diploma Date

State Certification Title of Certification

State(s) Issuing Agency

Type Date of Expiration

Recent Professional Development

Organization

CPUs

5728 Virginia Avenue Clarendon Hills, Illinois 60514

Tel. 630-654-0151 / Fax 630-654-0182 www.SetonMontessori.org

For office use only:

Amount received:

Check #:

Date:

How did you hear about Seton Montessori Institute? What aspects of your learning style should Seton be aware of? Please describe.

Language(s) Spoken

Montessori Certification Identify Montessori teacher credentials held and the organization granting the credential (eg. AMS, AMI or other).
Certification Program and Organization Certification Program and Organization Certification Program and Organization Location Location Location Date Certified/Level(s) of Certification Date Certified/Level(s) of Certification Date Certified/Level(s) of Certification

Employment Background
Current Employer Previous Employer Position Position From/To From/To

Experience with Children
School Other experiences with children Position From/To

References (List the individuals who you have requested to write references for you)
Name Name Name Phone Phone Phone Position/Title Position/Title Position/Title Relationship to applicant Relationship to applicant Relationship to applicant

Practicum Phase Have you made arrangements for a Practicum site?
Practicum School Name School Administrator School Address Supervising Teacher Name and Email if known) School Montessori Affiliation

❑ No (notify us when you do

❑ Yes, please complete the following:

Administrator Phone and Email City,State/Zip Code School Phone Number

5728 Virginia Avenue Clarendon Hills, Illinois 60514

Tel. 630-654-0151 / Fax 630-654-0182 www.SetonMontessori.org

Documentation Needed to Submit a Complete Application ☐ are enclosed ☐ are on file College transcripts: Evaluation Reports: ☐ transcripts need to be evaluated (by WES.org or ece.org ☐ Evaluation Reports are enclosed ☐ is enclosed

☐ are being sent

If applicable, a copy of my previous Montessori credential:

☐ is on file

A check for my application deposit is enclosed in the amount of: ☐ $500 (I understand that $100 of this is non-refundable should I not be accepted or choose to postpone or withdraw from the program). How will payments be made? ☐ Self ☐ Other

☐ School Sponsored Do you need information on student visas? ☐ Yes ☐ No

Non-Discrimination Statement It is the policy of Seton Montessori Institute not to discriminate against any individual on the basis of race, color, religion, national origin, sex, marital status, age or veteran status in matters of admissions, unemployment, or services or in the educational programs it operates, in accordance with civil rights legislation and institutional commitment. Admissions Deadlines We have priority admission deadlines for the following programs and will continue to accept applications after the priority deadlines (if space is available). March 1, 2013: Spring Infant-Toddler and Early Childhood Credential Programs May 1, 2013: Summer Infant-Toddler and Early Childhood Credential Programs April 30, 2012: Elementary I and Elementary I-II Credential Programs A $200 late enrollment fee will apply to applications processed after the published deadline.

I understand that my application will not be processed unless the following items have been received: • $500 Application payment • I have enclosed my transcripts/evaluation reports • I am having my transcripts/evaluation reports sent directly to Seton Montessori Institute Please make all checks payable to: Seton Montessori Institute. Applications are dated upon receipt and acted upon in the order received. Enrollment is limited. You will be called for an interview as soon as your application is processed. Submit to: Seton Montessori Institute Attn: Elizabeth Norman, Admissions/Records Coordinator 5728 Virginia Avenue Clarendon Hills, IL 60514

Applicant Signature

Date

5728 Virginia Avenue Clarendon Hills, Illinois 60514

Tel. 630-654-0151 / Fax 630-654-0182 www.SetonMontessori.org

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