Skip To Content

You are here:  Departments > Graduate Education > Grad Ed Quick Application
Graduate Education Quick Application
Please complete the Graduate Education Quick Application below. When you have reached the end of this application, press <Submit>.

Personal Information
*
First Name
Middle Name
*
Last Name
Suffix
*
Mailing Address
*
City
*
State
*
Zip
*
County of Residence
*
Country
*
Primary Phone Number
*
Email Address
*
Social Security Number
*
Date of Birth
*
Gender

*
Ethnicity





*
Hispanic/Latino


Enrollment Information
*
Current College/University (if none, write none)
*
Please list all current KY Teaching Certifications (if none, write none.)
Have you ever attended Georgetown College? 
If so, what year(s) did you attend?
How did you hear about Georgetown College?
*
Term Applying For:
*
Course(s) Requested (Please use section & number, i.e. EDU510):
 To search for course offerings, please click here.
 
To view the course catalog, please click here. (The Graduate section begins on page 293.)
*
I understand that a maximum of two, 3 hour courses taken as a visiting student may be considered for transfer into full degree seeking program in Graduate Education at Georgetown College.
(By selecting "yes," you signify that you agree to these terms.)

For re-certification applicants only:  Do you anticipate enrolling in a Master of Arts in Education within the next 5 years?

For students taking a course for transfer to another university program ONLY:  It is required that your program advisor forward an email to grad@georgetowncollege.edu giving permission for you to take this course and list the course number.

 
Code of Ethics & Privacy (FERPA)
Code of Ethics
 
For the full Code of Ethics form, please click here.
 
*
1.   Have you ever had a professional certificate, license, credential, or any document issued to you for practice denied, suspended, revoked, or voluntarily surrendered?

*
2.   Are you currently being reviewed or investigated for purposes or such action as stated in #1 or is such action pending?

*
3.   Have you ever been dismissed, resigned, released, or asked to resign/retire or discharged from a professional position or military service for immorality, incompetence, willful neglect of duty, misconduct, or presenting false information toward obtaining the position?

*
4.   Is any such action as stated in #3 pending?

*
5.   Have you ever been convicted of a felony or misdemeanor (other than a moving traffic violation), been found guilty, or entered a plea of 'nolo contendere' (no contest), even if adjudication was withheld, in Kentucky or any other state?

*
6.  If you indicated 'yes' to any items, #1 through #6, has that action been reviewed by the Education Professional Standards Board?

Date of Review
Explanation
*
I affirm and declare that all information given by me on this form is true, and correct, and complete to the best of my knowledge. I understand that any misrepresentation of facts, by omission or addition, may result in the denial or revocation of my teaching certificate. Further, I understand that KRS 161.120 provides that a teaching certificate may be revoked at any time upon determination that false information was presented toward obtaining a teaching certificate.
 
I declare that I understand the standard for personal and professional conduct expected of a professional educator in Kentucky. I further certify that I have read and examined the CODE OF ETHICS applicable to school personnel, understand its provisions, and agree by its terms during the course of my career as a professional educator.
RELEASE OF EDUCATIONAL RECORDS
 
Under the Family Education Rights and Privacy Act (FERPA), Georgetown College is permitted to disclose information from your educational records to your parents, if your parents (or one of your parents) claim you as a dependent for federal tax purposes. 
*
I have read and agree to abide by the Technology Ethics Policy as outlined at http://www.georgetowncollege.edu/its/its-policies/technology-ethics-policy/

*
Do your parents claim you as a dependent for federal income tax purposes?

*
I hereby authorize Georgetown College to release my educational records to my parents/guardians named below.

Name
Phone
(###) ###-####
Street Address
City
State
ZIP

 Acknowledgements
*
Today's Date
This application form and all supporting documentation will remain on file for 18 months.