CLARION UNIVERSITY OF PA

Online Early Childhood Directors Certificate Program

(Valid for One Semester Only)       

Please complete the top portion of the form completely.  Use N/A for items that do not apply.   Items with an * are required entries.

Last Name*:          First Name*:         Middle Initial:   

Former Names: 

Street Address*:           City*:         

State*:                   Zip*:                 Email Address: 

Birthdate:  (MM/DD/YYYY)       Sex:   Select M F       Race:    Select White, Non-hispanic Asian or Pacific Islander Black, Non-Hispanic Hispanic American Indian/Alaska Native Prefer not to answer

Daytime Phone Number:          Home Phone Number*:     

PA Resident*:       Select Yes No         If yes, name of county:                

Have you attended a college*:     Select Yes No

If you have attended another college,  College Name*:         

College GPA:      College Attendance Dates: 

High School Attended:      Dates Attended: 

High School City and State: 

GED:    Select Yes No               If GED earned, date GED was received: 

Have you attended Clarion University previously?         Select No Yes

Term for which you are applying*:    Spring   Summer   Fall       Year for which you are applying*:      
                                                    

Program you are applying for:  Online Early Childhood Directors Certificate Program

How did you hear about the online Early Childhood Directors Certificate Program? Please Select Clarion Website Email Direct Mail Telephone Friend, relative, or colleague Newspaper Search Engine (i.e. Google) Professional Organization Affiliation Other

This form must be completed each semester of enrollment.

This form can only be used for the online Early Childhood Directors Certificate Program.

Before classes can be scheduled, applicants must have FBI, Act 33, and 34 clearances.
Information on getting clearances can be found here.

By clicking the submit button, you are verifying that the information provided is accurate.