- Social Security Number: Applying for Year FallSpringSummer
- Name (last, first, m.i.):
- Previous Names Used:
- Mailing Address:
- City: State: Zip:Phone (with area code):
- Birthdate(mm/dd/year)
(Check one) Male Female
- Ethnic Origin (Response to this question will not affect the
admissions decision and is optional).
This information is requested
so that we may demonstrate to federal and state agencies that
the institution is in compliance with appropriate regulations.
- White (non-Hispanic) Latino/Hispanic Asian or Pacific
Islander
- Black(Non-Hispanic) American Indian
or Alaskan Native
-
- Illinois Resident? Yes No
How long? Years Months
- U.S. Citizen Non U.S. Citizen
--- Country:
- Perm. Resident
Alien -- Alien Registration:
-
- In case of emergency contact:
- ParentGuardianSpouse Name:
- Colleges or Universities
attended including Eastern.
Use reverse chronological order, beginning with most recent.
- Name/Campus
- 1.City State
- Dates Attended Degree/Hours Earned
-
Name/Campus
- 2.CityState
- Dates Attended Degree/Hours Earned
-
Name/Campus
- 3.CityState
- Dates Attended Degree/Hours Earned
- Employment history related
to child development. Use
reverse chronological order, beginning with most recent.
-
Name of Busniess/Agency
- 1.City State
- Dates Employed Position/Title
-
Name of Busniess/Agency
- 2.City State
- Dates Employed Position/Title
-
Name of Busniess/Agency
- 3. City State
- Dates Employed Position/Title
- Requirements
for participation in ABC include:
- Admitted
as an undergraduate at Eastern Illinois University, Board of
Governor's Program
- Evidence
of employment in an agency/center serving young children
- Evidence
of having completed an Associate of Science or an Associate of
Arts degree in Early Childhood or a related field
- Signature____________________________________
Date______/______/_____
- Mail this
completed application to: Donna Coonce, School of Family and Consumer Sciences,
Eastern Illinois University, 600 Lincoln Avenue, Charleston,
IL 61920-3099
|