PERSONAL RECOMMENDATIONS: (Required for 5 th year students only) Name Phone Position

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1 WESTMONT COLLEGE Teacher Credential Program Application for Admission PERSONAL INFORMATION: Student ID # LEGAL NAME: FIRST MIDDLE LAST ADDRESS: SCHOOL ADDRESS PERMANENT MAILING ADDRESS CITY STATE ZIP CODE CITY STATE ZIP CODE HOME PHONE: ( ) CELL PHONE: ( ) ADDRESS: SOCIAL SECURITY NUMBER: - - DATE OF BIRTH: - - DRIVER S LICENSE #: PLACE OF BIRTH: Have you ever been arrested for anything other than a minor traffic violation? q YES q NO If yes, attach an explanation. State law stipulates that anyone convicted of a felony is not eligible for a teaching credential in California without a hearing to determine fitness to hold a credential. ETHNICITY: Hispanic/Latino of any race? q YES q NO RACE: Check all that apply. q American Indian or Alaska Native q Asian q Black or African American q Native Hawaiian or Other Pacific Islander q White PREREQUISITE EXPERIENCE WITH CHILDREN and/or ADOLESCENTS: If you successfully completed ED 100 or 101 with 40 hours of fieldwork experience in classrooms, list the semester taken: grade level teacher school If you have had additional teacher aide experience in schools please describe: If you have NOT taken ED 100 or 101, document at least 100 hours of organized experiences with children or youth. List hours in chart. Youth Leader or Sunday School Teacher Scout Leader Teacher Aide/Tutor Recreation Leader Camp Counselor Other: PERSONAL RECOMMENDATIONS: (Required for 5 th year students only) Name Phone Position

2 ACADEMIC PREPARATION: Class level during Credential Year: q SENIOR q 5 th YEAR ($500 deposit due immediately upon acceptance for 5 th year students) Date of Graduation: Undergraduate degree-granting institution: GPA (submit transcripts) Major(s): Minor: Concentration : Credential sought: q PRELIMINARY MULTIPLE SUBJECT (Elementary) List grade levels desired for student teaching: q q PRELIMINARY SINGLE SUBJECT (Generally used in secondary school). List content area: Interested in student teaching in Costa Rica Course Semester Completed Plan for completion ED 100 or 101: Explorations in Teaching ED 105: Cultural Diversity ED 160 or 161: Computers for Teachers ENG 106: Language Acquisition KNS 156: Health for the Classroom Teacher U.S. Constitution HIS 171 or POL 10 (or approved waiver exam) ED 130: Special Education (typically taken with Methods courses) TESTING (Content Knowledge/Basic Skills): TEST Date Taken Date Passed Date Failed Retake Date CBEST (for single subject candidates only) CSETs (List each subset required for your area.) * If CSETs are not completed by March 1 attach evidence of test registration. CERTIFICATES OF CLEARANCE (Live Scan/Fingerprinting) Obtain live scans from Education office. Submit copies of completed live scan forms with application. Santa Barbara County Office of Education Date of live scan Date paid online fee to the CTC N/A Date cleared California Commission of Teacher Credentialing I understand that fifth year students are required to live off campus during their semester of student teaching. I understand that student teaching is similar to a full-time job, and I will seek to limit other responsibilities. My signature below indicates that all the information contained in my application is complete, factually correct and honestly presented. If admitted to the Teacher Preparation Program at Westmont College, I agree to abide by the college regulations and to support the values of the college as stated in the Community Life Statement, which I have read. Signature of Applicant Date

3 1. Personal Interests and Achievements: Indicate your interests, abilities, hobbies, honors, and/or offices held. (Please HAND PRINT.) 2. Teaching as a Profession: Indicate your reasons for selecting teaching as a profession. (Please HAND PRINT.) 3. Organized Experiences with Children and/or Adolescents: Briefly describe organized experiences with children or adolescents, especially noting experiences in culturally or socio-economically-diverse settings. (Please HAND PRINT.)

4 4. Philosophy of Education: (Please HAND PRINT.) Update May 2013

5 5. Autobiography: (Please write in CURSIVE.) Update May 2013

6 For Use of the Teacher Candidate Selection Committee 1. Citizenship Limitations 2. Legal Limitations 3. Prerequisite Experiences a. Education 100 or 101 b. Contact Hours Verification 4. G.P.A. 5. Recommendations/Action: q Accepted q Denied COMMENTS:

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