Lone Star College System
-76200228600Alternative Teacher Certification Program Application Packet(Use the following checklist to ensure you have completed all application requirements)You will only be considered for a screening interview with the Admissions Committee when you have submitted all items. To help make sure no items are misplaced, it is best to submit the items all at the same time so your interview can be scheduled. It is the applicant’s responsibility to confirm all items have been received and to contact the office to set up interview date/pleted ApplicationOfficial (sealed) college transcript(s) from all school attended (excluding highschool)$40 application fee receipt paid online or form completed by Business Office in Registration.Essay “Why I Want to Be a Teacher”Resume demonstrating knowledge in content area.3 professional recommendations Basic Skills Test scores for one of the following assessments taken within 5 PASS: Reading 81+, Writing 59+, Math (Algebra) 39+, Essay 5+ACCUPLACER: Reading Comprehension 81+, Sentence Skills 80+, Elementary Algebra 63+, Essay 6+ACT: Composite score of 23 with a minimum of 19 on the English test and/or mathematics testSAT: combined verbal and mathematics score of 1,070 with a minimum of 500 on the verbal test and/or the mathematics test.English Proficiency Test: Compass/ESL test scores: Reading 80+, Grammar 84+, Listening 82+ and a total score of 244+.Lone Star College-CyFair Alternative Teacher Certification Program9191 Barker Cypress Rd.Mod. 1 #110Cypress, Texas 77433Kathy Bliss, M Ed. Program CoordinatorEmail: Cy-Fair.TCP@lonestar.edu281-290-3957 FAX: 281-290-5932-76200-182245Name (circle one) Mr. Mrs. Ms. Miss.?Last First MiddleMust be as it appears on driver licenseMaiden NameAddress : Street Number Apt. number? City State ZipHome Phone Number Alternative Phone Number Driver’s License Number State Expiration DateEmail Address Social Security Number Date of Birth (mm dd yyyy) Gender M FEthnicity:Hispanic/Latino of any race yes noRace: Check all that applyAmerican Indian or Alaska Native Asian Black or African AmericanNative Hawaiian or Other Pacific IslanderWhiteTwo or more racesBachelor’s Degree conferred ________/________/_________ by _________________________________________ Month Day Year College/UniversityLocated in _________________________________________ Major _____________________ GPA ____________Additional DegreesCollege/UniversityCity/StateDate ConferredHave you served in the military? No Yes Which branch? ______________________________ When? ________________________ Have you applied to a teacher certification program before? No Yes When? ___________________ Where? _________________________Have you ever worked in a public school under a deficiency plan or emergency permit? No Yes When? _____________________ Where? _______________________Have you ever taught in the Texas public schools? No YesIf yes, where? ____________________________________________________________ Work Experience: In the space below, please list positions you have held previously. You may include any volunteer positions you feel may be relevant to this application. Please put an “*” beside any employment or volunteer position where you had an opportunity to work with children. If more space is needed, please attach another sheet of paper or include in your resume. School District or Firm NameYour PositionAddressCity/State/ZipArea Code/TelephoneImmediate SupervisorFull or Part TimeDates EmployedHave you ever been convicted of a felony? No YesAre you a citizen of the USA? No Yes Do you have Permanent Resident Status? No Yes (please provide us with a copy) Is English your first language? No YesOther than English, what languages do you speak/write?Language ______________________________________________ Speak WriteLanguage ______________________________________________ Speak WriteLSC-CyFair Alternative Teacher Certification ProgramCandidate AgreementAPPLICANT: Submit this signed agreement with your application packet.I understand I must submit the non refundable application fee of $40 for my application to be reviewed by LSC-CyFair Alternative Teacher Certification Program.I affirm statements by me in this application are true and accurate to the best of my knowledge. I understand any false statements, misrepresentations or omission made by me during the application process shall be grounds for refusal to be admitted to the program.I agree to abide by the Lone Star College-CyFair testing and assessment requirements.I understand that the State Board for Educator certification (SBEC) will complete fingerprinting and a criminal background check before issuing a probationary teaching certificate.I hereby authorize LSC-CyFair to investigate through whatever means deemed appropriate and facts resulting from the investigations to determine my suitability for acceptance into the program. I release LSC-CyFair Teacher Alternative Teacher Certification Program from any liability in connection with the investigation.I understand that meeting the eligibility requirements does not guarantee me an interview or acceptance into the program and being interviewed does not guarantee me admission into the program.I agree to abide by the policies, procedures, rules and regulations of the LSC-CyFair Teacher Alternative Certification Program.I agree to pay for each course taken before the start date of each class in order to keep my place in the program. I understand that tuition and fees are subject to change and are non-refundable.I understand that if accepted into the program I MUST take course work in the same semester or next semester. If you feel the cost of the course isn’t currently in your budget, then delay application until you are able to pay and attend the required course.I hereby authorize LSC-CyFair Alternative Teacher Certification to release application information for interview screening and employment purpose to school districts.By applying to and registering at LSC-CyFair I agree to abide by the Student Discipline Policy and Student Rights and Responsibilities regulations published in the Lone Star College System catalog and the Student Handbook.I UNDERSTAND AND AGREE TO THE ABOVE ITEMS:PRINT NAME: ______________________________ DATE: __________________________ SIGNATURE OF APPLICANT: ____________________________________________________ Certification Area WorksheetCertification area based on transcript core courses: English, Math, Science, Social Studies, Speech. The following will help you evaluate your transcript(s) to see if you have enough hours.EC-6 Generalist (39 semester hours) 4-8 Generalist (39 semester hours)4-8 ESL Generalist (39 semester hours)4-8 Math, Science, Social Studies, ELAR (18 sem hrs)8-12 ELAR, Math, Science*, Social Studies (24 semester hours)8-12 Science Composite (36 semester hours in combination) (Bio, Chem, Phys, Earth Science, Phy Nat Science) 8-12 Social Studies Composite (36 semester hours in combination) (Hist, Govt, Econ, Pol Sci) ESL Supplemental 12 semester hours English & 18 hours in Math, Social Studies, Natural Science and SpeechEC-12 Special Ed Supplemental – 3 hours Psych on transcript. FORMCHECKBOX English Language Arts & Reading (8-12) FORMCHECKBOX Math (8-12) FORMCHECKBOX Music (EC-12) FORMCHECKBOX Physical Science (8-12) FORMCHECKBOX History (8-12) FORMCHECKBOX Physical Edu (EC-12) FORMCHECKBOX Speech (8-12) FORMCHECKBOX Health (EC-12) FORMCHECKBOX Art EC-12 FORMCHECKBOX Life Science (8-12) FORMCHECKBOX Theatre (EC-12) Please complete the following essay by responding to the following question in complete sentences using proper grammar and punctuation; use an additional page if necessary. PLEASE PROOF THOROUGHLY. A Word document may be attached, if you prefer.Why do you want to be a teacher?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________095250-6858095250 Alternative Teacher Certification ProgramRecommendation FormProfessional Recommendation For: ________________________________________________ (Applicant’s Name)The above applicant has selected you as a source of reference. We would appreciate your comments as to the applicant’s qualifications. NOTE: When this reference is received in the Alternative Teacher Certification Program office, it is held strictly confidential and not revealed to the above named applicant. Check appropriate column for each item belowSuperiorAbove AverageAverageFairPoorDo Not KnowAbility to present ideasWork HabitsProfessional attitudeRapport with peersResourcefulnessReliabilityCooperationProfessional appearanceEnthusiasmOther:Additional Comments:________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Reference Contact InformationDate: _____________ Signature ____________________________________Name _______________________________________Position _____________________________________Firm ________________________________________Telephone ___________________________________Address ______________________________________City/State/Zip ________________________________Please return this recommendation in a sealed envelope to the candidate that is asking for the reference-87630-1905 Alternative Teacher Certification ProgramRecommendation FormProfessional Recommendation For: ________________________________________________ (Applicant’s Name)Social Security Number: _________________ Date: _____________ Date Due: ____________The above applicant has selected you as a source of reference. We would appreciate your comments as to the applicant’s qualifications. NOTE: When this reference is received in the Alternative Teacher Certification Program office, it is held strictly confidential and not revealed to the above named applicant. Check appropriate column for each item belowSuperiorAbove AverageAverageFairPoorDo Not KnowAbility to present ideasWork HabitsProfessional attitudeRapport with peersResourcefulnessReliabilityCooperationProfessional appearanceEnthusiasmOther:Additional Comments:________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please return this recommendation to:Kathy Bliss, M Ed.Lone Star College-CyFairAlternative Teacher Certification Program9191 Barker Cypress Rd. Mod. 1 #110Cypress, Texas 77433FAX: 281-290-5932Reference Contact InformationName _______________________________________Position _____________________________________Firm ________________________________________Telephone ___________________________________Address ______________________________________City/State/Zip ________________________________Signature ____________________________________ -182880110490Alternative Teacher Certification ProgramRecommendation FormProfessional Recommendation For: ________________________________________________ (Applicant’s Name)Social Security Number: _________________ Date: _____________ Date Due: ____________The above applicant has selected you as a source of reference. We would appreciate your comments as to the applicant’s qualifications. NOTE: When this reference is received in the Alternative Teacher Certification Program office, it is held strictly confidential and not revealed to the above named applicant. Check appropriate column for each item belowSuperiorAbove AverageAverageFairPoorDo Not KnowAbility to present ideasWork HabitsProfessional attitudeRapport with peersResourcefulnessReliabilityCooperationProfessional appearanceEnthusiasmOther:Additional Comments:________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please return this recommendation to:Kathy Bliss, M Ed.Lone Star College-CyFair Alternative Teacher Certification Program9191 Barker Cypress Rd. Mod. 1 #110Cypress, Texas 77433FAX: 281-290-5932Reference Contact InformationName _______________________________________Position _____________________________________Firm ________________________________________Telephone ___________________________________Address ______________________________________City/State/Zip ________________________________Signature ____________________________________Alternative Teacher Certification Program9191 Barker Cypress Rd. Mod. 1 #110 / Cypress, Texas 77433-1383(281) 290-3957 / FAX 281-290-5932NOTE: DO NOT SEND CASH OR CHECK TO THE ATCP OFFICE, ALL FEES SHOULD BE HANDLED BY THE BUSINESS OFFICENon-AR Payment WorksheetPREFERRED: Pay the ATCP application fee online, the registration fee # is in the current online catalog, using CATCP 7000010 rubric.SECONDARY: Take this form to the Business Office payment counter Learning Commons (one stop Registration Center). Bring a copy of the receipt toAlternative Teacher Certification in Mod. 1 #110 with your application.Candidate Name: _______________________________________________LSCS student- MERGEFIELD "Larry_Norris_Sonography_Students_Spring" ID or Social Security #____________________ FORMCHECKBOX Alternative Teacher Certification Application Fee10-80-9-980400-5115 $40.00 Business Office Use Only:THIS FORM IS TO BE KEPT ON FILE.Date: Receipt Number: Session Number: Amount Paid: ................
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