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# SCHOOL OF EDUCATION AND HUMAN DEVELOPMENT Undergraduate Student Teaching Application Information

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

##  Other requirements

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.

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<div style="text-align: center;">KSU School of Education & Human Development Supervised Teaching Applicant Data and Agreements</div>


<div style="text-align: center;"><img src="imgs/img_in_image_box_134_202_2293_1697.jpg" alt="Image" width="84%" /></div>


## Agreements

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.

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<table border=1 style='margin: auto; word-wrap: break-word;'><tr><td colspan="4">Kentucky State University School of Education Student Teacher Medical Exam</td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Name:</td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'>DOB:</td><td style='text-align: center; word-wrap: break-word;'>Exam Date:</td></tr></table>

## Medial History (Completed  in advance by student teacher applicant)

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: ___

## Physical Examination (Completed by Health Care Provider)

General health: ___

Height: _____

blood pressure:_____ pulse:_____

weight:_____

___eyes/vision ___ears/hearing

___ nervous system

___dental respiratory system

___ circulatory system

___ digestive system

___endocrine system

___musculoskeletal 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: