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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