UMF Office of Graduate Studies 111 South Street Farmington, ME 04938
Revised April 2019
Intent to Participate - Graduate Education Certificate Program
For more information please visit http://www2.umf.maine.edu/gradstudies/certificate/
Please complete and return to: gradstudies@maine.edu OR fax (207) 778-8134
Last Name _________
_____________________ First Name ___________________________ Middle ______________
Preferred Name _________________ Previous names (e.g.: maiden name) ___________________________________
Have you ever applied to or taken classes at a University of Maine System School (including job applications)? _______
Gender ______ Date of Birth _____________ Student ID (if known) _______________
Preferred email address________________________________________ Preferred Phone _______________________
Mailing Address ___________________________________________________________________________________
Current School District/Agency__________________ Current School__________________________________________
Current Position _____________________________________________________ Number of Years Teaching ________
Program Plan
Preferred semester to start your coursework: Year _______ Fall
Spring
Summer
Do you have a Baccalaureate degree?
Yes No
Do you have a Master’s degree?
Yes No
Please indicate the Graduate Education Certificate program in which you intend to participate:
Administration
a
Systems of Student Support
Assistive Technology
English Language Learning
Gifted and Talented Education
Math Coaching
b
Math Intervention Specialist
Math Leadership
Proficiency Based Education
Special Education Administration
Special Education Elementary
Special Education Secondary
a
Administration certificate applicants must submit evidence of two (2) years of teaching experience
b
Math Coaching certificate is only available to members of the Maine Mathematics Coaching Project (MMCP)
If you have taken any UMF graduate courses that are applicable to this certificate, please list them. (Only courses that
have been taken in the last five (5) years, with a grade of B or higher, can be applied to this program.)
__________________________________________________________________________
Note: Acceptance to any of the certificate programs listed above does not constitute acceptance to any UMF graduate
degree program. If you wish to enroll into a graduate degree program, you must submit a separate application.
Signature __________________________________________________ Date ____________________
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signature
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