Microcredential Application

Academic Information

I acknowledge that registering for the microcredential will generate a charge to my account. I will be required to pay the bill by the deadline before being given access to the course.

Yes

Please choose which Microcredential you are interested in:

Science of Reading Fundamentals

Do you have a State-issued Teaching Certificate / Licensure?

Yes, I hold an active initial NYS teaching certificate

Yes, I hold an active professional NYS teaching certificate

No, I do not hold an active NYS teaching certificate at either the initial or professional level

Please note: You may be asked to submit a copy of your certification if we are unable to confirm based on the information you provided.

By submission of this form, I authorize SUNY New Paltz to register me for EDI699, Science of Reading Fundamentals.
I acknowledge that registering for classes will generate charges and these charges will be reflected on an invoice sent to my.newpaltz.edu account.

Yes, I agree

If "yes", at which level(s) do you hold active certification (check all that apply):

Early Childhood Education (B-2)

Childhood Education (1-6)

Adolescence Education (7-12)

Under what name(s) do you hold active teaching certificates (i.e., Sarah Smith, Sarah Smith Jordan)?

Requested Start Date

Academic Background

Are you a P-12 teacher?

Yes

No

What best describes your reason for signing up for this microcredential?

If "Other", please explain:

What State do you teach in?

Which school district do you currently teach in?

Are you full or part time employee?

Part-Time

Full-Time

Which teaching/administrative level best describes you?

If "Other", please explain:

Have you previously applied to SUNY New Paltz?

Yes, I applied and was accepted as a matriculated student

Yes, I applied and was NOT accepted as a matriculated student

No, I have not previously applied to SUNY New Paltz

Have you been dismissed from a college for disciplinary reasons or convicted of a felony?

Yes

No

Personal Information

First Name

Chosen/Preferred First Name

Middle Name

Last Name

Former Last Name

Birthdate

Email Address

Primary Phone Number

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Mailing Address

Country

Street

City

Region

Postal Code

Demographic Information

Are you Hispanic/Latinx?

Yes

No

Please indicate your race (check all that apply):

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Please indicate your legal sex:

Female

Male

Other

Please indicate your gender identity:

Female

Male

Nonbinary

No

Please indicate if you are one of the following:

U.S. Military Veteran

U.S. Military Service Member - Active Duty

U.S. Reserves National Guard

Spouse of U.S. Military Service member

Child of U.S. Military Service member

Child of U.S. Military Veteran

Dependent of Veteran and/or Service Member

Spouse of U.S. Military Veteran

Not a service member, veteran, spouse or child of service member/veteran

Residency

Are you a citizen or permanent resident of the U.S.?

Yes

No

Have you been a permanent resident of New York State for the last twelve months or more?

Yes

No

Current county of residence

My country of citizenship is:

Emergency Contact Information

First Name

Last Name

Email Address

Phone Number

Country

Street

City

Region

Postal Code

Certification

I certify that the information given in this application for admission is complete and correct. I understand that any falsification or omission of data may result in the denial of admission or disciplinary action.

Signature