STUDENT TEACHING APPLICATION DATA FORM



-114300114300STUDENT TEACHING APPLICATION DATA FORMEducation of Students With Exceptionalities (ESE)LAST NAME: FORMTEXT ?????FIRST NAME: FORMTEXT ????? FSUSN: FORMTEXT ?????SSN (last four digits only): FORMTEXT ?????APPLICATION FOR (Semester of Internship): FALL FORMCHECKBOX SPRING FORMCHECKBOX YEAR FORMTEXT ?????WHERE DID YOU ATTEND: (NAME OF SCHOOL, CITY AND LOCATION)COMMUNITY COLLEGE: FORMTEXT ?????DATES FORMTEXT ????? TO FORMTEXT ?????UNIVERSITY: FORMTEXT ?????DATES FORMTEXT ????? TO FORMTEXT ?????HIGH SCHOOL: FORMTEXT ?????DATES FORMTEXT ????? TO FORMTEXT ?????JUNIOR/MIDDLE SCHOOL: FORMTEXT ?????DATES FORMTEXT ????? TO FORMTEXT ?????EXPECTED DATE OF GRADUATION FROM F.S.U.: FORMTEXT ????? DEGREE: FORMTEXT ?????Do you have relatives in the school system of your choice? Yes FORMCHECKBOX No FORMCHECKBOX If yes, explain the relationship, position and location in district: FORMTEXT ?????Physical conditions that should receive consideration in placement: FORMTEXT ?????FULL NAME: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? LastFirstM.I.LOCAL ADDRESS: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Street AddressApt Cell Phone # FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? CityStateZIP CodePERM.ADDRESS: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Street AddressApt Phone # FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? CityStateZIP CodeFSU EMAILADDRESS: FORMTEXT ?????Emergency Contact InformationFULL NAME: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????LastFirstM.I.ADDRESS: FORMTEXT ?????Street Address FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CityStateZIP CodePRIMARY/ CELL PHONE: FORMTEXT ?????RELATIONSHIP: FORMTEXT ?????Personal InformationList major courses completed or to be taken before internship. Include approved equivalent courses.Enter credit hours and indicate semester you have taken/will take the course.Course Prefix/NumberTeaching FieldCourse TitleSemHoursSemTakenEEX4770Study of Human Exceptionality3 FORMTEXT ?????EEX4834Introductory Practicum in Special Education2 FORMTEXT ?????EEX4201Typical and Atypical Development and Learning3 FORMTEXT ?????EEX4014Introduction to Mental Disabilities3 FORMTEXT ?????TSL4080Language Principles for Teachers3 FORMTEXT ?????EEX3601Applied Behavior Analysis for Special Education3 FORMTEXT ?????EEX3831Practicum in Direct Observation2 FORMTEXT ?????EEX4250Individualized Reading Instruction for Students with Disabilities 3 FORMTEXT ?????EEX4070Including Students with Disabilities in the General Education Curriculum3 FORMTEXT ?????EEX4251Teaching Math to Learners with Disabilities3 FORMTEXT ?????EEX4050Introduction to Learning and Behavior Disabilities3 FORMTEXT ?????EEX4223Individual Educational Planning3 FORMTEXT ?????EEX4212Educational Assessment for Students with Disabilities3 FORMTEXT ?????EEX5258Advanced Reading Instruction for Students with Disabilities3 FORMTEXT ?????EEX4941Practicum with Students with High Incidence Disabilities2 FORMTEXT ?????EEX5765Introduction to Special Education Technology3 FORMTEXT ?????TSL4081Teaching English Learners3 FORMTEXT ?????EEX4253Functional Reading and Life Skills for Individuals with Disabilities3 FORMTEXT ?????EEX4842Practicum with Students with Low Incidence Disabilities2 FORMTEXT ?????EEX4930Nature of Autism and Sever Communication Disorders3 FORMTEXT ?????EEX5237Methods for Teaching Students with Low Incidence Disabilities3 FORMTEXT ?????EEX5286Preparing Individuals for Transition3 FORMTEXT ?????EEX4751Collaboration with Families, Schools, and the Community 3 FORMTEXT ?????EEX5920Pre Student Teaching Seminar1 FORMTEXT ?????EEX5235Instructional Environments: Ethical, Legal, Safety, and Classroom Management3 FORMTEXT ?????EEX8966Master’s Comprehensive Examination0 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Course Prefix/NumberReading RequirementCourse TitleSemHoursSemTakenRED4510Teaching Reading in the Elementary School3 FORMTEXT ?????AUTOBIOGRAPHICAL STATEMENT*Each student teacher/intern applicant is required to write an autobiographical essay that may be read by potential Cooperating Teachers and Principals when considering your placement. The purpose of the essay is to provide a means for introducing the student teacher/intern to the Cooperating Teacher and Principal. The following questions may be used to help create an essay: 1. Why did you choose teaching as a career?2. What previous teaching experiences have you had? (Be specific)3. What special skills or talents do you have that might allow you to make special contributions during student teaching?4. Are there particular student activities with which you would like to assist while student teaching?*Type your essay in a Word document and title it, “Autobiographical Statement.” Proof read your essay document thoroughly and ask at least two other persons to read your essay for clarity, professionalism, and accuracy (grammar, spelling, etc). Replace this page with your essay.OFFICE OF ACADEMIC SERVICES AND INTERN SUPPORT (OASIS) ● (850) 644-3760NAME OF APPLICANT: FORMTEXT ?????Note. Students should NOT contact schools or districts concerning placements. The College and school districts have developed placement procedures and protocols, often different for each district. The school districts require the Office of Academic Services and Intern Support to handle all requests or inquiries concerning placements.Note. Students requesting Infant/Toddler and Preschool level placements will indicate “level choice” only. Students requesting elementary, middle, or high school level placements must choose both level, type of disability, and service delivery model.Level choices: FORMCHECKBOX Infant/Toddler (birth to 3 years) FORMCHECKBOX Preschool (3 - 5 years) FORMCHECKBOX Elementary FORMCHECKBOX Middle FORMCHECKBOX Secondary/TransitionDisability choices (indicate for elementary, middle or high school level placements only): FORMCHECKBOX Autism spectrum disorder FORMCHECKBOX Emotional handicaps FORMCHECKBOX Intellectual disabilities FORMCHECKBOX Learning disabilities FORMCHECKBOX Profound/Multiple disabilities FORMCHECKBOX Severe disabilities FORMCHECKBOX Severe emotional disturbanceService Delivery Model FORMCHECKBOX Center school FORMCHECKBOX Inclusion FORMCHECKBOX Resource room FORMCHECKBOX Self-contained on a general education campusAdditional Comments: FORMTEXT ?????I agree to fulfill all of the commitments and obligations of the student teaching placement as described in the FSU Student Teaching Handbook. I further agree for FSU to release to school districts my course grades, unofficial transcript, and FTCE test scores (GK, PED, SAE: ESE) as required by school districts to secure a student teaching placement. I also acknowledge that all placements are subject to availability and district and school acceptance of student teachers. Therefore, placements are not guaranteed. _____________________________________________________________________APPLICANT SIGNATUREDATE_____________________________________________FSU STUDENT NUMBER* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *ACADEMIC PROGRAM RECOMMENDATION:As a representative of our ESE program, I have reviewed this application. This applicant has completed or will complete all course requirements for internship and has demonstrated development in the 12 Florida Educator Accomplished Practices such that I recommend approval of this applicant to student teach/intern._________________________________________________________________ACADEMIC PROGRAM REPRESENTATIVEDATELAST NAME: FORMTEXT ????? FIRST NAME: FORMTEXT ?????FSUSN: FORMTEXT ?????PREFERRED STUDENT TEACHING LOCATIONDesignate 1st choice, 2nd choiceArea I(6 counties)Area II (per program approval)(10 counties)Area III(2 counties)Area IV(6 counties)Area V(1 district) FORMTEXT ????? Gadsden FORMTEXT ????? Bay FORMTEXT ????? Lake FORMTEXT ????? Hillsborough FORMTEXT ????? FSU/Pembroke Pines K-5 School FORMTEXT ????? Jefferson FORMTEXT ????? Calhoun FORMTEXT ????? Orange FORMTEXT ????? Manatee FORMTEXT ????? Leon FORMTEXT ????? Franklin FORMTEXT ????? Pasco FORMTEXT ????? Madison FORMTEXT ????? Jackson FORMTEXT ????? Pinellas FORMTEXT ????? Taylor FORMTEXT ????? Gulf FORMTEXT ????? Polk FORMTEXT ????? Wakulla FORMTEXT ????? Holmes FORMTEXT ????? Sarasota FORMTEXT ????? Liberty FORMTEXT ????? Okaloosa FORMTEXT ????? Walton FORMTEXT ????? WashingtonOTHER LOCATIONS REQUESTED/COMMENTS: FORMTEXT ????OFFICE USE ONLYCHECK LIST FOR ADMISSION TO STUDENT TEACHING YES NO1. Admitted to Teacher Education FORMTEXT ????? FORMTEXT ?????2. Advisor’s Signature FORMTEXT ????? FORMTEXT ?????3. Departmental G.P.A. met in all FSU Coursework FORMTEXT ????? FORMTEXT ?????4. Departmental G.P.A. met in Teaching Field FORMTEXT ????? FORMTEXT ?????5. Professional Education G.P.A. met FORMTEXT ????? FORMTEXT ?????6. Professional Education required hours met FORMTEXT ????? FORMTEXT ?????OFFICE USE ONLY ................
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