Application to the Professional Program
Elementary Education Certification
E
CCSU School of Education and Professional Studies
203 Henry Barnard Hall; Phone: 860-832-2125
Undergraduate and Post Baccalaureate certification students must be admitted to the Professional Program for Teacher
Certification before they can take or pre-register for professional program courses.
Application Submission deadline (or next regular day of classes if date falls on a weekend or holiday):
Fall Semester: September 10
Spring Semester: February 10
Complete applications may be submitted between the start of the semester and the application deadline.
Please print or type
Last Name (please print)
First Name
Middle Initial
Mailing Address
Home Phone
CCSU ID
Apt. #
Cell Phone
Former Last Name(s)
City/State/Zip
Email EMAIL WILL BE SENT TO
YOUR CCSU EMAIL ACCOUNT
Gender  Female
Date of Birth (MM/DD/YY)
 Male
Ethnicity/Race (Optional) Ethnicity (check one) Hispanic or Latino Not Hispanic or Latino
Race (mark all that apply) American Indian / Alaska Native Asian Black / African American Native Hawaiian / Pacific Islander White
 First Time
Application
 Reapplication Semester previous application submitted: _____________________
Use from old application: Essay Recommendations Praxis scores/waiver Transcripts Experience forms
Entering Level
 Undergraduate  Graduate/Post Baccalaureate
 I am or will be a graduate of a Connecticut Community College Pathways to Teaching Careers program.
Program
Elementary Education Academic/subject matter major: _______________________ Subject Major Advisor: _________________________
Praxis Tests Students receiving disability or non-native English speaker accommodations should contact the Assistant Dean for application
accommodation information.
 PRAXIS Waiver–attach a copy of official waiver letter.  PRAXIS CORE Tests–you will be contacted if your scores are not on file.
Note: if you passed all three Praxis I tests by 9/1/2014, you may use them for this application. They will be accepted for certification until 7/1/2019.
Institutions Attended (Except CCSU)
List all colleges and universities you have attended (undergraduate and graduate) and attach official transcripts from all except CCSU.
Transcripts submitted to other CCSU offices cannot be used. Use a separate piece of paper if you need more space.
College/University
City/State
Month/Year Attended
to
Undergraduate/Graduate
to
to
Statement of Criminal Background
1. Have you ever been convicted of any crime, excluding minor traffic violations?
2. Have you ever been dismissed for cause from any position?
3. Have you ever surrendered a professional certificate, license, permit or other credential (including, but
not limited to, an education credential); had one revoked, suspended, annulled, invalidated, rejected or
denied for cause; or been the subject of any other adverse or disciplinary credential action?
4. Is there any other legal issue/pending case that might appear on a background report that you think you
should discuss with the Assistant Dean? For instance, you must pass a criminal background check to
participate in field experiences. Arrests and accelerated rehabilitation programs show on the report until
the case is disposed or rehabilitation complete. These can impact our attempts to find field placements.
YES NO
YES NO
YES NO
YES NO
NOTE: If you answer “YES” to any of the above questions, you will be asked to meet with the Assistant Dean and submit a
signed statement explaining each incident with applicable court or administrative record(s).
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Application to the Professional Program—Elementary Education Certification
Name
CCSU ID:
Requirements for Admission
(Please read all instructions and requirements completely)
Submit all documents and meet all requirements listed below;
 Undergraduate students—have completed 45 hours total, or Post-Baccalaureate Certification students—bachelors degree,
admission to graduate studies, and completed or enrolled in 6 hours at CCSU.
 Overall cumulative grade point average (GPA) of 2.70 at CCSU and a cumulative 2.70 GPA on all undergraduate coursework taken
at all institutions.
 Undergraduate Students only: Minimum 2.70 GPA in major, with no grade less than C- in major courses, calculated on a minimum
of 15 credits but including all courses in major.
 Pass a second on-site departmental essay AFTER the application is submitted. The Teacher Education Department will post signup sheets for this essay in Barnard 226. You are responsible for signing up for the essay.
 Pass an interview with a faculty team conducted AFTER the application is submitted, demonstrating an acceptable standard of
knowledge, skills, and professional dispositions important to effective teaching performance.
 The Teacher Education Department will assign your interview date and time and POST the schedule outside Barnard 226. You are
responsible for checking this schedule for your Interview time.
 NOTE: CCSU reserves the right to seek additional information from faculty and others concerning candidates for admission.
All students submit (Please mark if required document is included in application materials): Note: We recommend that transcript and
waiver/ testing requirements be done 2-3 months before the application deadline to allow time for processing.
 Completed application form, signed and dated, with name written on every page of all documents;
 Praxis Core waiver letter from Connecticut Department of Education attached to the application or Praxis Core test scores
reported directly to CCSU. Praxis scores should be on file with CCSU when application is submitted. You will be notified if
scores are not on file. You are responsible for submitting scores even if you previously asked ETS/Praxis to report scores to
CCSU. Applications will not be processed without the Praxis requirement met. Students receiving disability or non-native
English speaker accommodations should contact the Assistant Dean for application accommodation information.
 Official non-CCSU transcripts from all institutions attended even if coursework did not transfer to CCSU. Have transcripts sent
directly to you and submit them with the application. “Issued to Student” transcripts with official signatures and/or on transcript
paper may be submitted. The Assistant Dean orders CCSU transcripts.
 Two recommendations (signed originals) related to your ability to work with children The recommendations should be on the
Recommendation for Elementary Education form (in rack outside Barnard 203). One recommendation must be from a faculty
member in your subject matter major. The other must come from a professional who has observed your work with children.
Recommendations from family members are not acceptable.
 Essay demonstrating a command of the English language, describing why you want to teach and enroll in the Professional
Program for Teacher Certification, emphasizing experiences relevant to teaching. Essay must be typed.
 Document 30 hours of quality experience with children, using the “Statement of Experience with Children” form in the rack outside
Barnard 203. Baby-sitting or parenting experience is not acceptable.
 Completion of these courses with a grade of C or better. Indicate the grade earned in each. If using a course substitution, also write
SUB. Write “Now” if you are currently enrolled in a course. Courses must be completed before full admission is granted.
ENG 110 ________; MATH 113 or MATH 213 ________ (Note—both Math 113 and 213 require a grade of C but only one must
be completed before Professional Program admission); American History course _____________________________; PSY 236
________; PSY 362 or 361________; EDTE 210 ________; EDT 210 ________.
 Resume addressing your educational and work experiences.
 Course and work schedule indicating availability for interviews.
Graduates/Post-Baccalaureate Certification Students should also submit:
 Photocopies of the Graduate School admission letter and the official Planned Program Worksheet (with appropriate signatures).
Submit complete application materials in person, not by mail, to the Assistant Dean, School of Education and Professional Studies, 203
Barnard Hall. INCOMPLETE APPLICATIONS MAY NOT BE PROCESSED. If you have questions or issues, contact the Assistant
Dean, School of Education and Professional Studies before the application deadline.
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Application to the Professional Program—Elementary Education Certification
Name
CCSU ID:
Statements of Understanding
Read Before Signing!
I understand that to be accepted into the Professional Program, complete the Professional Program, and obtain a recommendation from
CCSU for Connecticut certification, I must demonstrate the following:
 Professional attitudes and attributes appropriate to a teacher.
 Conduct that demonstrates appropriate professional behavior and shows realization that actions reflect directly upon the status and
substance of the profession.
 Confidentiality of all information concerning colleagues and students obtained in the educational process.
 Integrity and honesty in written and verbal communication, documentation, and coursework.
 Adherence to the Connecticut Code of Professional Responsibility for Teachers.
I further understand that the Dean of the School of Education and Professional Studies may revoke my admission if:
 My cumulative GPA drops below 2.70.
 I demonstrate unprofessional behavior or an inability to respond appropriately in various contexts that affect my performance as a
teacher.
 I falsify or misrepresent any documentation or information for programmatic, academic, or professional qualification/competency
purposes.
 I demonstrate unacceptable performance in field experiences or student teaching.
 I fail to achieve an acceptable level on required School of Education and Professional Studies assessments.
 Other due or sufficient cause.
I further understand that
 Connecticut law requires that I complete a fingerprint-based criminal background check before participating in field experiences or
student teaching and that I am responsible for obtaining the background check.
 any pending incident, including arrests and accelerated rehabilitation, may appear on my criminal background report and result in
school districts not accepting me for field experiences or student teaching.
 if I have been convicted of a crime, dismissed for cause, or surrendered a professional credential, I might not be admitted to the
Professional Program, may be unable to participate in field experiences or to student teach, or may be ineligible for CCSU’s
recommendation for certification. This decision is at the discretion of the Dean of the School of Education and Professional Studies.
Furthermore, I understand that even if I receive the CCSU recommendation for certification, the Connecticut State Department of
Education may not grant me certification.
 if I am arrested after admission to the Professional Program, I must report the incident to the Assistant Dean of the School of
Education and Professional Studies within 5 days of the incident.
 if I fail to pass the background check, I may be unable to complete my chosen program at CCSU. I understand that the University is
not responsible for my inability to complete my chosen degree or certification program.
I further understand that
 It is my responsibility to provide up-to-date, official transcripts (transcripts marked “issued to student” are acceptable) from all
colleges/universities that I have attended and that transcripts submitted to other CCSU offices cannot be used by the SEPS Assistant
Dean’s Office.
 If CCSU does not have my Praxis Core scores on file, I am responsible for submitting my score report to the Assistant Dean even if I
previously requested that test scores be sent to CCSU.
 All application materials become property of the Office of the Dean of Education and will not be returned.
I understand and agree to abide by the above Statements of Understanding. I attest that the information provided by me in this application
contains no willful misrepresentation or falsification and that all of the information given by me is true, complete and accurate. I understand
that this information may be verified and that any misrepresentation or falsification may result in the rejection of my application. I
understand that admission may be revoked if I fail to continue to meet program requirements.
Signature
Date
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Application to the Professional Program—Elementary Education Certification
Name
CCSU ID:
CCSU OFFICE USE ONLY
GRADE POINT AVERAGE is found on the Summary Report
COMMENTS
DEPARTMENTAL REVIEW & EVALUATION DECISIONS
GPA in Content/Major Area, calculated on a minimum of 15 credits in the major: _________
Essay: Please  check evaluation result below and attach completed essay criteria/score sheet.
Pass __________ Not Passed ___________ Passed on Redo __________
Name of Essay Reviewer 1
Name of Essay Reviewer 2
Comments:
Interview: Please  check evaluation result below and attach completed interview criteria/score sheet.
Pass __________ Not Passed___________ Passed on Redo __________
Name of Interviewer 1:
Name of Interviewer 2:
Comments:
Additional Comments:
RECOMMENDATION FOR PROFESSIONAL PROGRAM
Department Chair’s or
Coordinator’s Signature
Date
Admit

Not ready
to apply

Defer Reject


Reasons: (Please word reason for not ready,
deferral or rejection the way it should appear in the
student’s letter.)
Original Application
Dean’s Signature
Original Application
Deferral Clearance
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