Course Requested*

Please select all courses for which you are registering.

Early Childhood Course (students ages 2 1/2 - 6 years) Elementary I Course (students ages 6-9 years) Elementary II Course (students ages 9-12 years) Elementary Level II Stand Alone (9 through 12 years) Elementary I and II Course (students ages 6-12 years) Administrator Course MACAR – Beginning Level 1 MACAR – Advanced Level 2 MIE

Who is responsible for payment for this course?required

Organization Namerequired

Personal Information

First Namerequired

Last Namerequired

Maiden Name

Addressrequired

Cityrequired

Ziprequired (ex. 06108 or 06108-0809)

Staterequired

Mobile Phonerequired

Work Phonerequired

Best Email for Future Contactrequired

Are you a US Citizen?*

Yes No

School/Employer Detail

Employer or School Namerequired

Position Held (or Student)required

Address

City

Zip (ex. 06108 or 06108-0809)

State

Do you already have a school to do your Practicum?*

Yes No

Where?

What is the name of the school where you will be doing your Practicum? Practicum sites must be approved by SMTEC.

Education

Highest Degree Earnedrequired

Official Transcripts Required

School Namerequired

Graduation Daterequired (mm/dd/yyyy)

Montessori Credential

Copy Required

Montessori Training Center

Date of Montessori Certification

State Teaching Credential

State teaching credential held (copy required)

Have you ever been convicted or pleaded no contest for any violation of the law other than minor traffic offenses?*

yes no

Explain

Emergency Contact

First Namerequired

Last Namerequired

Mobile Phonerequired

Work or Home Phonerequired

The information supplied by me on this application is true and correct to the best of my knowledge.*

yes no