APPLICATION POSTMARK DEADLINE: OCTOBER 1, 2003 Please Note: OFFICIAL TRANSCRIPTS are required for university admission and program admission.

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1 CALIFORNIA STATE UNIVERSITY CHANNEL ISLANDS CREDENTIAL PROGRAM APPLICATION SPRING 2004 APPLICATION POSTMARK DEADLINE: OCTOBER 1, 2003 Please Note: OFFICIAL TRANSCRIPTS are required for university admission and program admission. Application to the CSUCI Credential Program is a two-step process, including a University Graduate Application, and Credential Program Application University Requirements Apply to the University. This requires that a Graduate Application be filed directly with the Office of Admissions or you may apply online at Contact the Office of Admissions at (805) for their deadline dates. Please refer to the Page 8 of this application for instructions to complete the University application. Send applications to: Office of Admissions CSU Channel Islands One University Drive Camarillo, CA Pay the University application fee of $ Arrange to have official transcripts mailed directly to the CSUCI Office of Admission from each college or university attended, including your degree posted and date awarded. Have your transcripts sent immediately; this is often a slow process. (If you do not yet have a transcript with your degree posted, you must submit an official transcript of your work completed to date and then provide an official transcript with your degree posted and date awarded as soon as it is available.) Education Program Requirements Apply to the Education Program using the remainder of this application. Enclose Credential Program Application Processing Fee: $25.00, check payable to CSUCI. Have official transcripts mailed to your home from each college or university attended, including an official transcript with your degree posted and date awarded. Send for your transcripts immediately, this is often a slow process. Please attach this set of official transcripts to the Education Program application and send to: Credentials Office CSU Channel Islands One University Drive Camarillo, CA (If you do not yet have a transcript with your degree posted, you must submit an official transcript of your work completed to date and then provide an official transcript with your degree posted and date awarded as soon as it is available.) The Multiple Subject Credential Program is accredited by The California Commission on Teacher Credentialing. CSUCI anticipates a positive response to its accreditation application for Single Subject and Special Education in Fall California State University Channel Islands (CSUCI) has applied for eligibility from the Senior College Commission of the Western Association of Schools and Colleges (WASC). WASC has reviewed the application and determined that CSUCI is eligible to proceed with an application for candidacy for accreditation. A determination of eligibility is not a formal status with WASC, nor does it assure eventual accreditation; it is a preliminary finding that the institution has potential for accreditation, and within two years of its eligibility determination will be reviewed for candidacy status with the Accrediting Commission at the California Commission on Teacher Credentialing. Questions about eligibility may be directed to CSUCI or to WASC at wascr@wascsenior.org or (510)

2 CSUCI Application: Choose One Credential Program Multiple Subject Credential Full-Time OR Single Subject Credential Full-Time OR Part-Time Part-Time (Select one: English, Mathematics, or Science) Education Specialist Full-Time OR Part-Time (Special Education, Mild/Moderate Level I) 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 Address: please print exactly (lower/upper case) Social Security # - - Date of Birth / / Gender: M F Ethnic Identity (Optional) School granting Bachelor s Degree: (Gathered for state reporting purposes only) Date of degree or anticipated date: Previously applied to or entered a credential program? Yes No List university and year: Academic Major: Please list ALL colleges and universities attended. ATTACH an official transcript from each, including coursework through University extension programs. Transcripts do not need to be in sealed envelopes. Name of Institution Date of Attendance Official Transcripts attached To Follow Official Transcripts attached To Follow Official Transcripts attached To Follow Official Transcripts attached To Follow PLEASE COPY ALL DOCUMENTS AND PAPERWORK SUBMITTED, FOR YOUR PROFESSIONAL FILE. 2

3 APPLICATION CHECKLIST To best serve applicants to the Education Credential Program and to facilitate the application process, please check all appropriate boxes verifying the status of each requirement and fill in ALL blanks for the requested information. Highest priority will be given to students who have complete files. We will continue to work with you to complete the requirements for admission, but we encourage you to consider placing yourself in the highest priority group to facilitate acceptance into the program. You may be Provisionally Admitted, or admitted as a Pre-Credential student, until all requirements are met. Consideration for admission requires a complete application file. The items listed on this Checklist are required to receive your credential. Interviews are scheduled only when the application file is complete. Education Program files must be completed by the application deadline to receive full consideration. 1. Graduate Application to the University Application has been submitted to the University. Date: Official transcripts from each college or university listed on Page 1 of this Application must be mailed or submitted directly to the Office of Admissions. 2. CBEST Exam (Must be passed by October 2003 for full Spring 2004 admission and advancement to methods courses) CBEST has been passed, and a copy of the score report/card indicating my test scores is attached. CBEST was taken on, and scores are pending. A copy of the score report/card indicating my test scores will be submitted as soon as received. CBEST exam will be taken on, and a copy of the registration confirmation is attached. Passing scores should be submitted to the Credentials Office when received for prompt consideration. 3. CSET/ SSAT Exam(s) OR Approved Subject Matter Preparation Program (Waiver) CREDENTIAL CSET/SSAT OR APPROVED WAIVER Multiple Subject Multiple Subjects Elementary Subject Matter English Single Subject English English Mathematics Single Subject Mathematics Mathematics Science Single Subject Science Science Educational Specialist CSET/SSAT Elementary or Secondary Subject Matter 3

4 Subject Matter Option 1: CSET/SSAT (Must be passed by October 2003 for full Spring 2004 admission and advancement to methods courses. Valid Praxis: MSAT scores are accepted for Multiple Subject and Special Education applicants) CSET/SSAT in (subject area) taken, and score report is attached. CSET/SSAT exam will be taken on, and copy of score report will be submitted as soon as received. Copy of exam scores is required even if you requested your scores to be reported to CSUCI. A copy of the registration confirmation must be attached. OR Subject Matter Option 2: Subject Matter Preparation Waiver Program Verification Please speak with the Credential Advisor for Current Information on Elementary Subject Matter Waivers by calling (805) Note that as of 7/1/2002 all students completing multiple subject credential programs must pass the CSET before being hired by school districts. Subject matter preparation program (waiver) completed or anticipated completion at CSU Channel Islands: Semester/Year Students who completed or are completing the Liberal Studies program at CSUCI do not need to submit a letter verifying program completion. Subject matter preparation program (waiver) completed at, or anticipated completion at: (college or university) Semester/Year of completion or anticipated completion Original waiver letter verifying completion or original letter verifying that a subject matter preparation waiver program is in progress is attached. Please note that a waiver letter verifying full completion of subject matter preparation will be required in order to recommend you for your credential. Please submit the completion waiver letter as soon as available. 4. Prerequisite Courses in Education You must receive a grade of C or better in all CSUCI prerequisites or equivalent courses. These courses must be taken within 5 years prior to beginning a credential program at CSU Channel Islands. CSUCI Education program staff will verify all courses that meet prerequisite requirements. If course substitution for courses taken at another university is requested, then attach Course Substitution form. These forms are available in the Credentials Office and our web site. A complete credential program application must be received in order to admit students to take prerequisite courses. Extended Education/Open University is also available for registration purposes. CSUCI Multiple Subject and Education Specialist Credential Program Prerequisites English 475 Language and Social Context Completed/In Progress at CSU Channel Islands Semester/Year: Course Substitution requested : Education 510 Learning Theory and Development Applied in Multicultural Education Contexts Completed/In Progress at CSU Channel Islands Semester/Year: 4

5 Course Substitution requested : Education 512 Equity, Diversity and Foundations of Schooling Completed/In Progress at CSU Channel Islands Semester/Year: Course Substitution requested: Special Education 345 Individuals with Disabilities in Society Completed/In Progress at CSU Channel Islands Semester/Year: Course Substitution requested : CSUCI Single Subject Credential Program Prerequisites English 475 Language and Social Context Completed/In Progress at CSU Channel Islands Semester/Year: Course Substitution requested : Education 512 Equity, Diversity and Foundations of Schooling Completed/In Progress at CSU Channel Islands Semester/Year: Course Substitution requested : Education 520 Observing and Guiding Behavior in Multicultural/Multilingual and Inclusive Classrooms Completed/In Progress at CSU Channel Islands Semester/Year: Course Substitution requested : Education 521 Field Experience Completed/In Progress at CSU Channel Islands Semester/Year: Course Substitution requested : Special Education 345 Individuals with Disabilities in Society Completed/In Progress at CSU Channel Islands Semester/Year: Course Substitution requested : 5

6 5. Field Experience form with classroom teacher recommendation. Documentation of at least 45 hours of field experience in a classroom that is appropriate for your credential is required. This form must be completed by a public school classroom teacher, principal, or supervisor and submitted with your application. Please include your Social Security Number on this form. The Field Experience form is the final page of this application. Attached 6. Two Letters of Recommendation from faculty or others who are knowledgeable about your personal qualities and potential to be a teacher are required. Letters of recommendation are non-confidential and should include your Social Security Number. These two letters are in addition to the Field Experience form. We prefer to see at least one letter of recommendation from a professional who can describe your work with students (such as a principal, supervisor, or teacher). 7. U.S. Constitution (College level course or exam covering the principles and provision of the U.S. Constitution) Please refer to your transcripts and complete all appropriate blanks. Credential program staff will verify this requirement when your application is reviewed, and if the requirement is incomplete, you will be notified, and provided alternatives in order to meet the requirement. Completed at: (college/university) Semester/Year completed: Title and Course Number: In Progress at: (college/university) Anticipated Semester/Year completion: Title and Course Number: Constitution Exam taken/is to be taken Score report verifying passing the exam is attached Score report verifying passing the exam will be submitted as soon as available 8. Tuberculin Clearance This is different than the proof of immunization required for admission to the University. TB Clearance is required prior to entering a public school classroom. The TB clearance is valid for 4 years and must remain valid throughout all student teaching experiences. Copy of TB results are attached. You can obtain the TB clearance through your personal physician or by contacting the CSUCI Health Center (805) Hours: M-TH 2pm-6pm F 1-5pm 9. Certificate of Clearance Application (41-CIC) or California Credential/Permit. Submit a copy of a Certificate of Clearance, California teaching credential, or your 30-Day, or Long Term Emergency Permit. Persons submitting copies of California credentials or permits do not need to submit form 41-CIC, Livescan or check for $ Expired credentials/permits are accepted. OR Submit completed form 41-CIC (blue form), a Livescan Service form completed by the applicant as well as the Livescan operator, and a check or money order for $27.50 made payable to the Commission on Teacher Credentialing, with your Credential Program application. You may call Linda Gowan (805) at the Ventura Office of the County Superintendent of Schools for current fees, times of fingerprinting, and an appointment. 6

7 As part of the admission process, candidates are advised that CONVICTION RECORDS may prevent a candidate from obtaining a credential. Although a wide variety of convictions will not prevent the issuance of a credential, the Education Code does stipulate that certain conviction records will mandate the denial of a teaching document. Candidates with conviction records must consult prior to applying with the Credential Advisor of the Credential Office regarding the nature of the conviction. Please call (805) for advisement. Have you ever been convicted of any felony or misdemeanor offense, including entering a plea of nolo contendere, in the state of California or any other state or country? YES NO 10. Official Transcripts Official Transcripts from each college or university attended as listed on page 1 of this Application are to be attached to this application. Please note that Transcripts for admission to the university must be mailed or submitted directly to the Office of Admissions. You do not need to submit an official transcript from CSUCI. Attached 11. Writing Sample Please write a word statement indicating why you desire to become a teacher, what you can contribute to the profession, and your interest in teaching the students with the many languages, cultures and diversity we see in the California schools. 12. Credential Program Application Processing Fee A $25.00 check made payable to CSUCI. 13. An interview for qualified candidates Information regarding interviews will be mailed to you only when your application is complete. Students are not eligible for financial aid until admitted to the Credential Program or as a Pre-Credential student. In order to be admitted to the Credential Program the application must be completed, all requirements met and an interview successfully completed. MY SIGNATURE BELOW CONFIRMS THAT EACH OF THE PROGRAM REQUIREMENTS FOR ADMISSION HAS BEEN OR IS BEING COMPLETED AS INDICATED. Signature Date 7

8 FOR USE IN COMPLETING THE UNIVERSITY APPLICATION Please complete PART A of the University Graduate & Post-Baccalaureate application. You do not have to complete Part B PLEASE REFER TO THE INFORMATION BELOW TO COMPLETE QUESTIONS 10 AND 11 OF THE UNIVERSITY APPLICATION. 10a. Specify major/program objective for which you are applying UNDECLARED Code Indicate any option, emphasis, or concentration within this field (Leave Blank) 10b. What is your initial degree objective? Enter code in box 0 None 11. Education Credential Objective Y (This is the correct response if you are enrolling to take prerequisites or credential classes) Credential Objective Name (Write in Multiple Subject, Single Subject, or Special Education) Credential Code (enter 100 for Single Subject) (enter 200 for Multiple Subject) (enter 468 for Special Education) Note: Financial Aid is available only to students who are admitted to the Credential Program, or have submitted a complete Credential Program application and obtained program advising for admission within the category of pre-credential status. If an application has not been submitted, prospective students have the option of registering for credential program prerequisite courses through Extended Education/Open University. Additional information about the teacher credentialing process in California may be found at the California Commission on Teacher Credentialing information website: 8

9 Field Experience Verification Form Pre-requisite for the CSUCI Credential Program Name: SSN: Phone #: Instructions: 1. Answer items a, b and c. 2. Ask your supervisor or other appropriate person to sign and verify the information (d). 3. Submit the form with your credential application Who must complete this form? Students who are applying to CSUCI s Credential Program. Required experience: 45 clock hours of participation with a group(s) of school-aged children (K-12). Paid and volunteer experiences are acceptable. The experience can take place in both public and private institutions. One on one experience such as tutoring or coaching does not apply. a. Location of Field Experience: b. Type of experience: Please check one. Teacher s Aide/Assistant/Volunteer After School Program Aide/Volunteer Substitute Teacher Other: Sunday School Teacher or Aide Camp Counselor Boy Scout/Girl Scout/YMCA Volunteer c. Please explain what you did (attach sheet if necessary). d. Supervisor s Verification: Supervisor s Signature Position/Title Institution Date # of hours completed 9

10 FINAL CHECKLIST FOR APPLICATIONS Application to the University, including the $55.00 check payable to CSUCI Application to the Education Program CBEST Exam Subject Matter Competence verification Exam(s) status or verification letter from a California university. Questions pertaining to subject matter exams should be directed to Credential Advising, at (805) Students not able to provide subject matter competence verification prior to being interviewed will be admitted as Pre-Credential status. Prerequisite courses status Field Experience verification Two letters of recommendation U.S. Constitution Course/Exam status Tuberculin Clearance Certificate of Clearance or California teaching credential/permit copy Official Transcripts (for both the University and Education Program) Writing Sample Application Processing Fee of $25.00 payable to CSUCI 10