Early Childhood Educator certificate application

Thank you for your interest in the Early Childhood Educator certificate program. Program enrollment requires that you are currently employed in an early childhood setting or have access to an early childhood classroom for the application-based components of the program. The early childhood setting that you will be utilizing must agree to participate in the program, and you must secure a signature from leadership attesting to this. Access the fillable pdf agreement on this page.

You will not be able to save your progress, so be ready to complete this application in one session.

Name

Full First Name

Middle Name

Last Name

Preferred First Name (what you want to be called)

Contact Information

Address

Country

Street

City

Region

Postal Code

Email Address

Mobile Phone

May we text you at this number?

Yes

Biographical Information

Birthdate

Legal Sex

Gender

Female

Male

Nonbinary

Add another gender

My Gender

Pronouns

Race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific

Other

White

Are you Hispanic or Latino?

Yes

Citizenship Information

Primary Citizenship

Please answer below if you are a dual citizen.

Dual Citizenship

Are you a U.S. Permanent Resident?

Yes

Current/Desired Visa Type

Admission Information

Round

Round Always Create

Submitted

Application Method

Area of Study

Entry Term

Have you previously applied for admission to Butler University?

Yes

I would like to be considered for Scholarship Opportunities and/or External Funding support:

Yes

Have you ever been found responsible of a disciplinary violation at your previous high school, college or university for any action involving violence, physical force or the threat of physical force, a sexual offense, stalking, possession of a weapon, kidnapping, arson or any offense which caused harm to another person?

Yes

Please give the approximate date(s) of each incident, explain the circumstances and reflect on what you learned from the experience.

Within the last seven years after the age of 14, have you ever been convicted, or plead guilty or entered a plea of nolo contendere to a criminal offense involving violence, physical force or the threat of physical force, a sexual offense, stalking, possession of a weapon, kidnapping, arson or any offense which caused harm to another person? You should answer “no” if your conviction or plea has been sealed, expunged, or overturned or if you were arrested but not charged or convicted.

Yes

Please provide the details of your criminal conviction or adjudication and reflect on what you learned from the experience.

Academic History

High School Name

Ceeb Code

Level of Study

Employment

Current Employer

Do you currently work in a childcare setting or have access to a childcare setting for learning during this program?

Yes

Name of childcare setting

If your setting is not listed, then select the option “My center is not listed” and check the box below to provide additional information about your setting.

My center is not listed

Additional childcare setting information

Childcare setting type

Please Explain

This program utilizes current teachers in a childcare setting to work as cooperative teachers. Every program participant will be paired with a Cooperative Teacher (CT), an experienced early childhood educator employed at the early childhood setting, to support your professional journey. This individual must apply as a cooperative teacher to the program and have the support of the childcare setting. You are required to have a cooperative teacher assigned to you by the start of your program. If you don't yet have one, please work with the leadership of your early childhood setting to identify one for you.

Have you identified someone who can work with you as a cooperative teacher in your childcare setting?

Yes

Cooperative Teacher First Name

Cooperative Teacher Last Name

Cooperative Teacher Email

Cooperative Teacher Phone Number

We will reach out to the individual you have named and let them know the next steps to apply as a cooperative teacher.

Character References

Reference 1 First Name

Reference 1 Last Name

Reference 1 Email

Reference 1 Phone Number

Reference 2 First Name

Reference 2 Last Name

Reference 2 Email

Reference 2 Phone Number

Supporting Documents

In addition to two character references, we also require:

A program participation agreement from a childcare setting where you will complete the application-based components of the program
An official or unofficial copy of your high school transcript or equivalency showing date of graduation or completion OR An official or unofficial copy of your college transcript, if applicable

Those can either be uploaded below or can be submitted through your application status page at a later time. You will be emailed instructions about how to access your status page after you have submitted your application.

Upload High School or College Transcript

Upload Program Participation Agreement

Upload First Character Reference

Upload Second Character Reference

Program Expectations

Please read each of the following program expectations and acknowledge by checking the box.*

I understand that I must currently be employed in an early childhood setting or have access to an early childhood classroom for the application-based components of the program.

I further understand that the early childhood setting that I will be utilizing must agree to participate in the program, and I must secure a signature from leadership attesting to this.

I understand that if I am not currently employed in an early childhood setting that I must be in good standing to be hired at one, and I will be required to pass a background check and a drug screen.

Signature

I certify that the information contained in this application and all other materials submitted to Butler University are complete and accurate. I understand that any falsification, misrepresentation, or material omission of information may result in the University’s decision that I am not eligible for admission or, if I enroll, its decision to dismiss me, regardless of the date of discovery, at the sole discretion of Butler University. I understand that after submitting this application and other materials, I must update or supplement my responses if events occur that would change the responses previously provided to the University. I understand that if I fail to do so, the University has the right to take the actions described above in regard to my application or my enrollment.

I understand that all application materials become the property of Butler University.

Any student who decides to attend Butler University is expected to comply with all rules and regulations promulgated by the University. The University Bulletin is available on our website. The Student Handbook can be viewed here. I understand that Butler University may publish my photograph or photographs or videos in which I appear for marketing purposes. Butler University admits students without regard to their race, color, sex, age, national or ethnic origin, religion, sexual orientation, ancestry, military discharge or status, marital status, parental status, or any other protected status. Otherwise qualified persons are not subject to discrimination on the basis of disability.

Security and Fire Safety Information

Butler University is committed to assisting all members of the Butler community to collectively achieve a safe campus environment. The annual security and fire safety compliance document is available on the Butler University Police Department website.

Signing and submitting your application indicates that you agree to the certification and the other terms and conditions set forth above.

Signature