Student Teaching Application Form

Student Teaching Application Form

Complete this Student Teaching Application Form in full. Incomplete or unsigned applications may delay placement. By submitting this form the applicant certifies that all information provided is true and complete, authorizes verification of academic and background information necessary for placement, and acknowledges program requirements and standards set forth below.

Applicant Information

Date of Birth:    Student ID:

Academic Program Information

Cumulative GPA:    Credits Completed:

Student Teaching Placement Preferences

Experience, Qualifications and Attachments

Attachments included: Resume Official Transcript Certificates/LIC

Eligibility, Background & Health Information

Have you ever been convicted of a felony or misdemeanor that has not been expunged? Yes No

Do you have any physical or medical condition that may affect placement or require accommodation? Yes No    If yes, explain:

I authorize the program to conduct background checks and verify academic records required for placement, and I understand that an adverse finding may affect eligibility for student teaching. I agree to notify the program immediately of any charge or conviction that occurs after submission of this application.

Emergency Contact / Guardian Information

References (Minimum two)

Acknowledgments and Applicant Certification

By signing below, I certify that:

1. All information provided on this application and in accompanying documents is true, accurate, and complete. I understand that omission or falsification of information may result in denial of placement or removal from the program.

2. I consent to the release of academic records, evaluation reports, and background check results to cooperating school districts and clinical supervisors as necessary for placement and supervision. I understand that certain districts may require additional clearances before placement.

3. I will comply with the policies, standards, and behavioral expectations of both the college/university and the host school. I understand that failure to meet professional standards may result in reassignment or dismissal from student teaching.

4. I understand that placement decisions are at the discretion of the program and cooperating districts and may be influenced by availability, qualifications, background check outcomes, and health or safety considerations.

Acknowledgment of Academic Policies and Code of Conduct:
I have read and agree to abide by the program's academic policies, attendance requirements, professional conduct standards, and assessment procedures.

Program Use Only

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