Madonna University PDP Registration Form 9-2011
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Professional Development Program Permit to Register Form Registration must be submitted no later than 2 weeks after beginning the professional develo pment training. Send all correspondence to: College of Education – PDP Madonna University 36600 Schoolcraft Road Livonia, Michigan 48150 Contact us for assistance: Anne Morris - Director Janice Centers – Secretary 734-432-5697 [email protected] www.madonna.edu/PDP +Enrollment Status: New Student Returning Student +Educational Level: Bachelor’s Master’s and/or Doctorate +Citizenship: United States Resident Alien Non-Immigrant Alien – specify country: + Social Security Number (required for first time course registration): +Do you hold a Professional/Permanent Teaching Certificate: Yes No If no, please indicate your job position: Administrator School Psychologist Other (please list): *Ethnic/Racial Group: White, Non-Hispanic Hispanic Black, Non-Hispanic American Indian Asian or Pacific Islander +Required fields. *For statistical purposes only - responses are not required but would be greatly apprec iated. Tuition Rate: $150.00 per credit (pay in full only) Total number of graduate credits: Total Tuition: ($150 X # credits): Payment Options: 1. Online by MasterCard, American Express, Discover, Diner’s Club or electronic check 2. Submit this form with your personal check or money order. Tuition is non-refundable. Be sure to submit: 1. This completed Registration Form 2. Tuition payment 3. PDP Course Assignment upon completion of professional training program(s) Course Information: Are you participating in professional development training (workshop, conference, seminar) that is being offered by an organization that has already arranged graduate credit with our department? Yes No If yes, indicate the Madonna course #(s) and title(s) provided by the facilitator/ instructor: EDU # of Credits: Title: EDU # of Credits: Title: If no, please ensure that the training you plan to attend meets the criteria necessary to qualify for graduate credit. Information on what qualifies for graduate credit can be found on our web site: www.madonna.edu/PDP Name: ____________ _________ Student ID#: Last First Middle Address: ______________ ___________ Street City State Zip County: _____________ _________ E-mail address: Cell Phone: _______ Home Phone: _____ Work Phone: ____________________ Place of Employment (District/Bldg.): ____________ I agree that the information provided is accurate to the best of my knowledge. Student Signature: _____________________ ____________ Date: _______________ 1 $150 1 1
Transcript of Madonna University PDP Registration Form 9-2011
8/4/2019 Madonna University PDP Registration Form 9-2011
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Professional Development Program
Permit to Register Form
Registration must be submitted no later than 2 weeks after beginning the professional development training.
Send all correspondence to:
College of Education – PDP
Madonna University
36600 Schoolcraft Road
Livonia, Michigan 48150
Contact us for assistance:
Anne Morris - Director
Janice Centers – Secretary
734-432-5697 [email protected] www.madonna.edu/PDP
+Enrollment Status:New Student Returning Student
+Educational Level:Bachelor’s Master’s and/or Doctorate
+Citizenship:United States Resident Alien
Non-Immigrant Alien – specify country:+ Social Security Number (required for first time course
registration):
+Do you hold a Professional/Permanent Teaching
Certificate: Yes No
If no, please indicate your job position:AdministratorSchool PsychologistOther (please list):
*Ethnic/Racial Group:White, Non-Hispanic HispanicBlack, Non-Hispanic American IndianAsian or Pacific Islander
+Required fields. *For statistical purposes only - responses are not required but would be greatly appreciated.
Tuition Rate: $150.00 per credit (pay in full only)Total number of graduate credits:Total Tuition: ($150 X # credits):Payment Options:
1. Online by MasterCard, American Express, Discover,Diner’s Club or electronic check
2. Submit this form with your personal check or moneyorder.
Tuition is non-refundable.
Be sure to submit:1. This completed Registration Form2. Tuition payment3. PDP Course Assignment upon completion of
professional training program(s)
Course Information: Are you participating in professionaldevelopment training (workshop, conference, seminar) that isbeing offered by an organization that has already arrangedgraduate credit with our department?
Yes NoIf yes, indicate the Madonna course #(s) and title(s) provided bythe facilitator/instructor:EDU # of Credits:
Title:
EDU # of Credits:
Title:
If no, please ensure that the training you plan to attend meetsthe criteria necessary to qualify for graduate credit. Informationon what qualifies for graduate credit can be found on our website: www.madonna.edu/PDP
Name: ______________________________________________________________ Student ID#: _______________Last First Middle
Address: _______________________________________________________________________________________Street City State Zip
County: ______________________ E-mail address: ___________________________________________________
Cell Phone: ____________________ Home Phone: ___________________ Work Phone: ____________________
Place of Employment (District/Bldg.): ______________________________________________________________
I agree that the information provided is accurate to the best of my knowledge.
Student Signature: ______________________________________________ Date: ________________________
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$150
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