Graduate Study in Early Intervention
Application
for the Graduate
Specialization in Early Intervention
1. Name:
_________________________________________________
2. Social Security #:
________________________________________
3. Date of Birth:
____________________________________________
4. Home Address:___________________________________________
City/Town____________________State_____Zip Code________
5. Home Phone: _____________________________________________
6. Work Address:____________________________________________
City/Town____________________State_____Zip Code________
7. Work Phone: _____________________________________
8. Fax: _____________________________________
9.
E-mail:___________________________________________________
10. Program option to which you are applying:
_____ Master’s (M.Ed.) (includes courses to meet
requirements for Maine Department of Education endorsement, Teacher of Young Children with
Disabilities Birth to School-Age Five)
_____ Certificate of Advanced Studies (CAS) (includes courses
to meet requirements for Maine Department of Education endorsement, Teacher of Young
Children with Disabilities Birth to School-Age Five)
_____ Endorsement only (courses to meet requirements of Maine
Department of Education endorsement, Teacher of Young Children with Disabilities, Birth to
School-Age Five)
_____Other (Please
specify)
___________________________________________________________
___________________________________________________________
11. Education:
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City/State |
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Degree and Date
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12. Early Intervention, Early Care and Education, and/or
Related Employment:
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Dates |
Employer |
Address |
Position |
Responsibilities |
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13. Describe the professional activities you are currently
engaged in or that you have been involved in within the past five years which show your
leadership or potential for leadership in the field of early intervention.
Advocacy
Participation in professional organizations
Specialized training
Conference/workshop presentations
Participation in conferences and workshops
Professional writing/publications
Program development
Other
14. Describe your hobbies, special interests, creative activities, and/or community
involvement:
Signature:
___________________________________Date: ____________
Instructions: Print and complete this
application and the
Financial Support Agreement. Mail
them and copies of all college transcripts to:
Sandra Doctoroff, Ph.D.
Assistant Research Professor
Center for Community Inclusion and Disability Studies
48 Tandberg Trail
Windham, ME 04062
207/892-0455
866/230-4520(V/TTY)
Fax: 892-2330
