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Candidate: _____ Date: _____ Last First Middle Maiden

Last First Middle Maiden

Local Address: ___ Tel.: ___ Street City State Zip Code

Permanent Address: _____ Tel.: _____

Street City State Zip Code

E-mail Address: ___

KSU Student ID#: _____ Date of Birth: ____/____/____ Gender: _____

Ethnicity (Check one): □ Non-resident Alien □ Black, not Hispanic Origin □ Hispanic □ Asian/Pacific Islander □ American Indian or Alaskan Native □ White, not Hispanic

Major Area:

_____

Advisor:

___

Cumulative Grade Point Average of 2.75 or higher: ___ Credit Hours completed: ___

I hereby apply to the Kentucky State University Teacher Education Committee for admission to the EPP and provide evidence that I have achieved each of the following criteria for admission:

Admission to the Education Preparatory Program

Passed grades in all courses in the Liberal Studies Core

□ Grades C or about in all educational foundation courses and Education content courses

Passed Praxis II PLT (Provide a copy to the School of Education office)

Passed or Attempted Content Exam (Provide a copy to the School of Education office)

200 field experience hours with data submitted in KFETS and verified through documentation signed by mentor teachers

Three Completed Assessment of Professional Dispositions, Values, & Behaviors form (1 filled out by you and 2 others)

Clear national-level criminal report submitted to the placement district

Current physical examination report, including TB skin test or x-ray

□ Verification of current liability insurance obtained through (KEA)

Completed Forms and Paid fees required for graduation

I authorize the University to submit confidential credentials to the Teacher Education Committee for evaluation to determine my compliance with Kentucky State University Standards and regulations for admission to the EPP. I understand that if I am admitted to the EPP, it is my responsibility to maintain credentials that are in compliance with University and Kentucky standards and regulations; and if I plan to teach in a state other than Kentucky, I also have to be in compliance with that state's standards and regulations. Furthermore, I certify that answers submitted are true and accurate to the best of my knowledge, for falsified statements on this application or other documents, unsatisfactory academic progress, failure to maintain appropriate credentials, or disciplinary action by the university against me, shall be considered sufficient cause for the Teacher Education Committee to expel me from the EPP.

Signature: _____ Date: _____

Date: ___

DOB: _____ Exam Date: _____

Name: ___

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

___musculoskeletal system

___ digestive 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 performing the duties of student teaching except as follows:_____

Distributed Memory

Printed Name ___

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Signature

Date

Date