Disclosure and Affirmation Form

Students interested in enrolling in the Master of Elementary Education online program must submit a disclosure regarding criminal history and affirm liability insurance. Please complete the disclosure and affirmation form below. This document is required before being admitted to the program.

Applicant Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Email *

Disclosure Section

Applicants to the graduate programs in the School of Education are required to provide information about all convictions, civil infractions, and ordinance violations. An applicant to a graduate program who has been convicted of a misdemeanor or felony may be denied admission. If a student is convicted of a crime during his or her graduate program and it is the decision of the student’s department to dismiss, the student may appeal the decision to a College-level Hearing Board.

Have you ever been convicted of a misdemeanor or felony or admitted responsibility for civil infraction or ordinance violations? *

Affirmation Section

Have you passed the Georgia Ethics Exam or (for out-of-state educators), the equivalent required ethics verification? *

Do you have tort liability insurance? If you are a member of PAGE or GAE this is included with your membership.

I certify that the answers provided are complete and accurate to the best of my knowledge. Falsification, misrepresentation, or omission of information may result in denial of admission or subsequent removal from a graduate program in the School of Education.