CATHERINE LEAHY BRINE EDUCATIONAL CONSULTANTS, INC.
98 RANDOLPH STREET
S. WEYMOUTH, MA 02190
781-331-8826

APPLICATIOPN COVER SHEET FOR ALL PROGRAMS

*** A $150.00 NON-REFUNDABLE APPLICATION FEE MUST ACCOMPANY THIS COVER SHEET.


SEMESTER FOR WHICH I AM APPLYING (Circle One and Add the Year)
September __________        January__________        April__________

PROGRAM FOR WHICH I AM APPLYING (Circle One)

M. Ed with Professional License M. Ed with Initial License M.Ed with no license
12 Credit Professional License Only 21 or 24 Initial License Only  
Ed. Leadership M. Ed Ed Leadership CAGS  
Reading Specialist M.Ed Reading Specialist CAGS  

 

NAME: ________________________________________________________________________________________________________

                LAST

FIRST MI      MAIDEN/OTHER
ADDRESS:____________________________________________________________________________________

                   NUMBER/STREET

   
                 ____________________________________________________________________________________

                   CITY/TOWN

STATE ZIP CODE
HOME TELEPHONE: ______________________                  CELL PHONE________________________
SOCIAL SECURITY NUMBER: ___________________             MEPID_________________ Date of Birth ____________________
E-MAIL ADDRESS ___________________________________________________________

Ethnicity/Race (for reporting purposes, optional) Do you consider yourself Hispanic/Latino? ___ Yes ___ No
Select one or more of the following racial categories to describe yourself:
___ American Indian/Alaskan Native ___ Asian ___ Black or African American ___ Cape Verdean
___ Native Hawaiian or Pacific Islander ___ White


LICENSE CURRENTLY HELD FROM MA. DESE:
(Circle One)

PRELIMINARY

INITIAL

PROFESSIONAL

FIELD: ______________________________________(example: History, 5-8)


COHORT SITE PREFERENCE
(Circle One)
Brockton
Cape Cod
Weymouth

Dedham
Pembroke
OTHER__________________
****We will run a cohort anywhere as long as there are FIFTEEN applicants.****

PLEASE READ THIS SECTION CAREFULLY BEFORE SIGNING:


I understand that Catherine Leahy Brine, Inc. is not responsible for any misinformation given to the agency, office staff or instructors by me regarding my license from the Massachusetts Department of Elementary and Secondary Education. I understand that I must hold a Preliminary license to be enrolled in the Initial License Programs and the Initial License to be enrolled in the Professional.  I understand that if programs or regulations change the program and its requirements may change as well with or without notice.


APPLICANT'S SIGNATURE ______________________________________________________ DATE ____________________

     

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