madonna university pdp registration form 9-2011

8/4/2019 Madonna University PDP Registration Form 9-2011

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Professional Development Program 

Permit to Register Form

Registration must be submitted no later than 2 weeks after beginning the professional development training.

Send all correspondence to:

College of Education – PDP

Madonna University

36600 Schoolcraft Road

Livonia, Michigan 48150

Contact us for assistance:

Anne Morris - Director

Janice Centers – Secretary

734-432-5697 PDP@madonna.edu www.madonna.edu/PDP 

+Enrollment Status:New Student Returning Student

+Educational Level:Bachelor’s Master’s and/or Doctorate 

+Citizenship:United States Resident Alien

Non-Immigrant Alien – specify country:+ Social Security Number (required  for first time course

registration): 

+Do you hold a Professional/Permanent Teaching

Certificate:  Yes No

If no, please indicate your job position:AdministratorSchool PsychologistOther (please list):

*Ethnic/Racial Group:White, Non-Hispanic HispanicBlack, Non-Hispanic American IndianAsian or Pacific Islander

+Required fields. *For statistical purposes only - responses are not required but would be greatly appreciated.

Tuition Rate: $150.00 per credit (pay in full only)Total number of graduate credits:Total Tuition: ($150 X # credits):Payment Options:

1.  Online by MasterCard, American Express, Discover,Diner’s Club or electronic check 

2.  Submit this form with your personal check or moneyorder.

Tuition is non-refundable.

Be sure to submit:1.  This completed Registration Form2.  Tuition payment3.  PDP Course Assignment upon completion of 

professional training program(s)

Course Information: Are you participating in professionaldevelopment training (workshop, conference, seminar) that isbeing offered by an organization that has already arrangedgraduate credit with our department?

Yes NoIf yes, indicate the Madonna course #(s) and title(s) provided bythe facilitator/instructor:EDU # of Credits:

Title:

EDU # of Credits:

Title:

If no, please ensure that the training you plan to attend meetsthe criteria necessary to qualify for graduate credit. Informationon what qualifies for graduate credit can be found on our website: www.madonna.edu/PDP

Name: ______________________________________________________________ Student ID#: _______________Last First Middle 

Address: _______________________________________________________________________________________Street City State Zip 

County: ______________________ E-mail address: ___________________________________________________

Cell Phone: ____________________ Home Phone: ___________________ Work Phone: ____________________

Place of Employment (District/Bldg.): ______________________________________________________________

I agree that the information provided is accurate to the best of my knowledge.

Student Signature: ______________________________________________ Date: ________________________ 

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$150

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