Rebuilt HTML — PaddleOCR-VL (Baidu)

Items that must be presented for application to be considered complete

Student Teaching Applicant Data and Agreements

Assessment of Professional Dispositions, Values, and Behaviors form 1 filled out by you and 2 more by individuals indicated on the form

Copy of Praxis II scores

Medical exam with TB test (can be obtained from Betty White Health Center for free)

Proof of Liability Insurance (SNEA) 2018-2019

200 field hours recorded in KFETS and proof of 200 field hours (field verification forms)

Once you are placed in school system, you will have to go to the district Human Resources office to get a state and federal background check. You must provide a copy of the report to the School of Education and Human Development office.

I understand that the Teacher Education Committee (TEC) has the authority to support or deny my admission to Supervised Teaching, based on my application and performance, and to withdraw me from Supervised Teaching if I do not attain or maintain the required standards for admission and continuation.

I authorize the Coordinator of Supervised Teaching to review my grades, Praxis II scores, medical exam, and criminal history and to report and discuss relevant information concerning me with the Teacher Education Committee. I understand that information discussed in TEC meetings is confidential. It is my responsibility to notify the Coordinator of Supervised Teaching, in writing, of any exceptions to this authorization.

I understand that I am expected to follow the public school district calendar and all district policies, during Supervised Teaching, unless otherwise instructed. It is anticipated that Supervised Teaching in spring or fall will begin on the district's first teacher day. This date may be prior to the first day of KSU classes. The last day for Supervised Teaching is anticipated to be the last day of classes for KSU seniors.

I understand that, if I want to live in KSU housing during Supervised Teaching, I must inform the Coordinator of Supervised Teaching so that my name can be forwarded to the KSU Housing Department, in anticipation of my request. I am responsible for contacting the Housing Department myself, to make final arrangements for my housing. Residence halls usually open a week before KSU classes begin.

Applicant Signature

Date

Kentucky State University School of Education Student Teacher Medical Exam

Name: DOB: Exam Date:

Please explain any medical and psychological history that could impede your ability to participate fully in student teaching:

Accidents/injuries: Major surgeries: Pertinent family history (parents & siblings): ___

Medications: ___

General health: ___

Height:_____ weight:_____

blood pressure:_____ pulse:_____

___eyes/vision ___ears/hearing

___ nervous system ___ circulatory system

___ digestive system ___ musculoskeletal system

___dental respiratory system

___endocrine system

Tuberculin skin test or x-ray: date administered ___ date read: ___ results: ___

I certify that I have examined this individual and find him/her free of any medical problem or communicable disease that could interfere with his/her performing the duties of student teaching except as follows:

Printed Name

Signature

Date: