Payment Form for Cooperating Teachers



Payment Form for Cooperating Teachers

Semester Year: _____ Term Summer_____ Fall_____ Spring _____

Please check box if information has changed: ☐

Cooperating Teacher Name: ___________________________ Social Security ______________

Ethnicity: (e.g. Hispanic _____ Asian _____ Black or African American _______ White ______ Decline___ M______ F_________

Address: _______________________________________________________________________________

Street City State Zip

Phone: ( ) _________-_____________

Name of School _______________________________

Please list the student(s) you are supervising.

Elementary

Student Name____________________________ Grade ______ # of Weeks _______

Starting Date _________________ Ending Date ________________

Student Name____________________________ Grade ______ # of Weeks _______

Starting Date _________________ Ending Date ________________

Middle School

Student Name__________________________ Subject _____________Grade ____ # of Weeks _______

Starting Date _________________ Ending Date ________________

Student Name___________________________Subject ____________Grade_____# of Weeks_________

Starting Date____________________ Ending Date ________________

High School

Student Name___________________________ Subject _____________ Grade ____# of Weeks _______

Starting Date _________________ Ending Date ________________

Student Name _________________________ Subject_______________Grade ____# of Weeks ______

Starting Date __________________ Ending Date ________________________

Name of University Supervisor ______________________________________

Please return to Paula Gordon in room 255 in the College of Education or you can scan or email to:

Paula.gordon@louisville.edu or fax to: 502-852-2408

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TO PROCESS PAYMENT FOR SUPERVISING TEACHER, THE FOLLOWING INFORMATION MUST BE COMPLETED ALONG WITH THE TAXPAYER ID FORM (W-9) AND RETURNED TO THE DEPARTMENT OF TEACHING AND LEARNING EACH SEMESTER.

Fall semester supervising teachers deadline is Sept 30"8LNV²ºÊØâðJ L N P f ? º ¼ Þ à WXZdˆ‰ŠÒ

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