[ { "page": 1, "items": [ { "page": 1, "type": "TITLE", "location": { "l": 90, "t": 742.8, "r": 521.76, "b": 684.72 }, "text": "Kentucky State University\nSchool of Education Human Development and Consumer Sciences\nAdmission to Student Teaching Application", "reading_order": 0, "level": 1 }, { "page": 1, "type": "TEXT", "location": { "l": 280.32, "t": 686.16, "r": 331.92, "b": 675.12 }, "text": "(Please print)", "reading_order": 1 }, { "page": 1, "type": "TEXT", "location": { "l": 34.8, "t": 664.8, "r": 564.72, "b": 647.52 }, "text": "Candidate: _____ Date: _____\nLast First Middle Maiden", "reading_order": 2 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 458.52, "t": 677.4, "r": 563.04, "b": 654.84 }, "text": "Date", "field_kind": "text", "label": "Date", "pdf_field_name": "Date", "pdf_field_type": "Text", "reading_order": 3 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 84.48, "t": 676.68, "r": 408.24, "b": 654.84 }, "text": "Candidate", "field_kind": "text", 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"text": "E-mail Address", "field_kind": "text", "label": "E-mail Address", "pdf_field_name": "Email Address", "pdf_field_type": "Text", "reading_order": 14 }, { "page": 1, "type": "TEXT", "location": { "l": 34.56, "t": 551.52, "r": 540.96, "b": 539.04 }, "text": "KSU Student ID#: _____ Date of Birth: ____/____/____ Gender: _____", "reading_order": 15 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 109.2, "t": 563.76, "r": 270.36, "b": 541.2 }, "text": "KSU Student ID", "field_kind": "text", "label": "KSU Student ID", "pdf_field_name": "KSU Student ID", "pdf_field_type": "Text", "reading_order": 16 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 323.64, "t": 563.76, "r": 350.52, "b": 541.2 }, "text": "Date of Birth", "field_kind": "text", "label": "Date of Birth", "pdf_field_name": "Date of Birth", "pdf_field_type": "Text", "reading_order": 17 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 356.04, "t": 563.76, "r": 378.48, "b": 541.2 }, "text": "undefined", "field_kind": "text", "label": "undefined", "pdf_field_name": "undefined", "pdf_field_type": "Text", "reading_order": 18 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 381.96, "t": 563.76, "r": 417.96, "b": 541.2 }, "text": "undefined", "field_kind": "text", "label": "undefined", "pdf_field_name": "undefined_2", "pdf_field_type": "Text", "reading_order": 19 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 453.6, "t": 563.76, "r": 538.8, "b": 541.2 }, "text": "Gender", "field_kind": "text", "label": "Gender", "pdf_field_name": "Gender", "pdf_field_type": "Text", "reading_order": 20 }, { "page": 1, "type": "TEXT", "location": { "l": 34.56, "t": 526.08, "r": 569.04, "b": 497.04 }, "text": "Ethnicity (Check one): □ Non-resident Alien □ Black, not Hispanic Origin □ Hispanic\n□ Asian/Pacific Islander □ American Indian or Alaskan Native □ White, not Hispanic", "reading_order": 21 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 144.72, "t": 525.24, "r": 156.72, "b": 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"pdf_field_type": "CheckBox", "reading_order": 25 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 288.72, "t": 511.8, "r": 300.72, "b": 499.92 }, "text": "American Indian or Alaskan Native", "field_kind": "checkbox", "label": "American Indian or Alaskan Native", "pdf_field_name": "American Indian or Alaskan Native", "pdf_field_type": "CheckBox", "reading_order": 26 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 468.72, "t": 511.8, "r": 480.72, "b": 499.92 }, "text": "White, not Hispanic", "field_kind": "checkbox", "label": "White, not Hispanic", "pdf_field_name": "White not Hispanic", "pdf_field_type": "CheckBox", "reading_order": 27 }, { "page": 1, "type": "TEXT", "location": { "l": 33.84, "t": 481.44, "r": 86.4, "b": 469.2 }, "text": "Major Area:", "reading_order": 28 }, { "page": 1, "type": "TEXT", "location": { "l": 39.12, "t": 481.2, "r": 498.72, "b": 467.52 }, "text": "_____", "reading_order": 29 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 88.56, 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"b": 447.24 }, "text": "Cumulative Grade Point Average of 2.75 or higher", "field_kind": "text", "label": "Cumulative Grade Point Average of 2.75 or higher", "pdf_field_name": "Cumulative Grade Point Average of 275 or higher", "pdf_field_type": "Text", "reading_order": 35 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 462, "t": 469.8, "r": 571.56, "b": 447.24 }, "text": "Credit Hours completed", "field_kind": "text", "label": "Credit Hours completed", "pdf_field_name": "Credit Hours completed", "pdf_field_type": "Text", "reading_order": 36 }, { "page": 1, "type": "TEXT", "location": { "l": 33.6, "t": 433.92, "r": 568.8, "b": 409.68 }, "text": "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:", "reading_order": 37 }, { "page": 1, "type": "TEXT", "location": { "l": 49.44, "t": 396.48, "r": 274.56, "b": 384.96 }, "text": "Admission to the Education Preparatory Program", "reading_order": 38 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 53.659, "t": 395.117, "r": 59.46, "b": 387.866 }, "text": "", "field_kind": "checkbox", "label": "", "pdf_field_name": "Check Box1", "pdf_field_type": "CheckBox", "reading_order": 39 }, { "page": 1, "type": "TEXT", "location": { "l": 51.12, "t": 382.08, "r": 295.2, "b": 370.56 }, "text": "Passed grades in all courses in the Liberal Studies Core", "reading_order": 40 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 54.1424, "t": 380.131, "r": 59.9434, "b": 372.88 }, "text": "", "field_kind": "checkbox", "label": "", "pdf_field_name": "Check Box2", "pdf_field_type": "CheckBox", "reading_order": 41 }, { "page": 1, "type": "TEXT", "location": { "l": 51.36, "t": 367.2, "r": 426.96, "b": 355.68 }, "text": "□ Grades C or about in all educational foundation courses and Education content courses", "reading_order": 42 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 54.1424, "t": 364.662, "r": 59.9434, "b": 357.41 }, "text": "", "field_kind": "checkbox", "label": "", "pdf_field_name": "Check Box3", "pdf_field_type": "CheckBox", "reading_order": 43 }, { "page": 1, "type": "TEXT", "location": { "l": 50.4, "t": 352.8, "r": 354.96, "b": 341.28 }, "text": "Passed Praxis II PLT (Provide a copy to the School of Education office)", "reading_order": 44 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 54.6258, "t": 350.643, "r": 60.4268, "b": 343.391 }, "text": "", "field_kind": "checkbox", "label": "", "pdf_field_name": "Check Box4", "pdf_field_type": "CheckBox", "reading_order": 45 }, { "page": 1, "type": "TEXT", "location": { "l": 50.4, "t": 338.16, "r": 420.96, "b": 326.64 }, "text": "Passed or Attempted Content Exam (Provide a copy to the School of Education office)", "reading_order": 46 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 54.1424, "t": 336.624, "r": 59.9434, "b": 329.372 }, "text": "", "field_kind": "checkbox", "label": "", "pdf_field_name": "Check Box5", "pdf_field_type": "CheckBox", "reading_order": 47 }, { "page": 1, "type": "TEXT", "location": { "l": 51.84, "t": 324, "r": 563.04, "b": 312 }, "text": "200 field experience hours with data submitted in KFETS and verified through documentation signed by mentor teachers", "reading_order": 48 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 54.1424, "t": 322.121, "r": 59.9434, "b": 314.87 }, "text": "", "field_kind": "checkbox", "label": "", "pdf_field_name": "Check Box6", "pdf_field_type": "CheckBox", "reading_order": 49 }, { "page": 1, "type": "TEXT", "location": { "l": 51.84, "t": 309.36, "r": 551.04, "b": 297.36 }, "text": "Three Completed Assessment of Professional Dispositions, Values, & Behaviors form (1 filled out by you and 2 others)", "reading_order": 50 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 54.1424, "t": 307.135, "r": 59.9434, "b": 299.884 }, "text": "", "field_kind": "checkbox", "label": "", "pdf_field_name": "Check Box7", "pdf_field_type": "CheckBox", "reading_order": 51 }, { "page": 1, "type": "TEXT", "location": { "l": 51.36, "t": 294.48, "r": 362.4, "b": 283.2 }, "text": "Clear national-level criminal report submitted to the placement district", "reading_order": 52 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 54.1424, "t": 292.633, "r": 59.9434, "b": 285.382 }, "text": "", "field_kind": "checkbox", "label": "", "pdf_field_name": "Check Box8", "pdf_field_type": "CheckBox", "reading_order": 53 }, { "page": 1, "type": "TEXT", "location": { "l": 51.12, "t": 280.56, "r": 345.36, "b": 269.04 }, "text": "Current physical examination report, including TB skin test or x-ray", "reading_order": 54 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 54.1424, "t": 278.131, "r": 59.9434, "b": 270.879 }, "text": "", "field_kind": "checkbox", "label": "", "pdf_field_name": "Check Box9", "pdf_field_type": "CheckBox", "reading_order": 55 }, { "page": 1, "type": "TEXT", "location": { "l": 51.84, "t": 266.88, "r": 334.8, "b": 255.36 }, "text": "□ Verification of current liability insurance obtained through (KEA)", "reading_order": 56 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 54.6258, "t": 265.562, "r": 60.4268, "b": 258.311 }, "text": "", "field_kind": "checkbox", "label": "", "pdf_field_name": "Check Box10", "pdf_field_type": "CheckBox", "reading_order": 57 }, { "page": 1, "type": "TEXT", "location": { "l": 52.08, "t": 253.44, "r": 301.2, "b": 241.44 }, "text": "Completed Forms and Paid fees required for graduation", "reading_order": 58 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 53.659, "t": 252.026, "r": 59.46, "b": 244.775 }, "text": "", "field_kind": "checkbox", "label": "", "pdf_field_name": "Check Box11", "pdf_field_type": "CheckBox", "reading_order": 59 }, { "page": 1, "type": "TEXT", "location": { "l": 32.88, "t": 219.84, "r": 576.96, "b": 122.4 }, "text": "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.", "reading_order": 60 }, { "page": 1, "type": "TEXT", "location": { "l": 34.08, "t": 73.68, "r": 282, "b": 60.96 }, "text": "Signature: _____\nDate: _____", "reading_order": 61 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 81.96, "t": 86.4, "r": 281.16, "b": 63.84 }, "text": "Signature", "field_kind": "signature", "label": "Signature", "pdf_field_name": "Signature", "pdf_field_type": "Signature", "reading_order": 62 }, { "page": 1, "type": "TEXT", "location": { "l": 322.08, "t": 73.2, "r": 472.08, "b": 61.44 }, "text": "Date: ___", "reading_order": 63 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 346.08, "t": 86.4, "r": 470.52, "b": 63.84 }, "text": "Date", "field_kind": "text", "label": "Date", "pdf_field_name": "Date_2", "pdf_field_type": "Text", "reading_order": 64 } ] }, { "page": 2, "items": [ { "page": 2, "type": "TITLE", "location": { "l": 143.28, "t": 746.64, "r": 468.48, "b": 734.4 }, "text": "Kentucky State University of Education Student Teacher Medical Exam", "reading_order": 0, "level": 2 }, { "page": 2, "type": "TEXT", "location": { "l": 39.12, "t": 720, "r": 545.76, "b": 707.52 }, "text": "DOB: _____ Exam Date: _____", "reading_order": 1 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 68.04, "t": 722.52, "r": 243.24, "b": 709.68 }, "text": "Name", "field_kind": "text", "label": "Name", "pdf_field_name": "Name", "pdf_field_type": "Text", "reading_order": 2 }, { "page": 2, "type": "TEXT", "location": { "l": 34.32, "t": 719.76, "r": 245.52, "b": 707.28 }, "text": "Name: ___", "reading_order": 3 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 313.44, "t": 722.52, "r": 428.4, "b": 709.68 }, "text": "DOB", "field_kind": "text", "label": "DOB", "pdf_field_name": "DOB", "pdf_field_type": "Text", "reading_order": 4 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 485.28, "t": 722.52, "r": 545.52, "b": 709.68 }, "text": "Exam Date", "field_kind": "text", "label": "Exam Date", "pdf_field_name": "Exam Date", "pdf_field_type": "Text", "reading_order": 5 }, { "page": 2, "type": "TITLE", "location": { "l": 142.56, "t": 693.36, "r": 468.72, "b": 680.64 }, "text": "Medical History (Completed in advanced by student teacher applicant)", "reading_order": 6, "level": 2 }, { "page": 2, "type": "TEXT", "location": { "l": 33.84, "t": 668.88, "r": 573.12, "b": 517.68 }, "text": "Please explain any medical and psychological history that could impede your ability to participate fully in student teaching: ___\nAccidents/injuries: Major surgeries: Pertinent family history (parents & siblings): ___\nMedications:", "reading_order": 7 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 79.68, "t": 654.84, "r": 572.64, "b": 642.48 }, "text": "teaching [1]", "field_kind": "text", "label": "teaching [1]", "pdf_field_name": "teaching 1", "pdf_field_type": "Text", "reading_order": 8 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 36, "t": 641.28, "r": 572.52, "b": 629.04 }, "text": "teaching [2]", "field_kind": "text", "label": "teaching [2]", "pdf_field_name": "teaching 2", "pdf_field_type": "Text", "reading_order": 9 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 396.36, "t": 601.68, "r": 571.8, "b": 588.84 }, "text": "Accidents/injuries: Major surgeries: Pertinent family history (parents & siblings [1]", "field_kind": "text", "label": "Accidents/injuries: Major surgeries: Pertinent family history (parents & siblings [1]", "pdf_field_name": "Accidentsinjuries Major surgeries Pertinent family history parents siblings 1", "pdf_field_type": "Text", "reading_order": 10 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 36, "t": 587.64, "r": 572.64, "b": 575.4 }, "text": "Accidents/injuries: Major surgeries: Pertinent family history (parents & siblings [2]", "field_kind": "text", "label": "Accidents/injuries: Major surgeries: Pertinent family history (parents & siblings [2]", "pdf_field_name": "Accidentsinjuries Major surgeries Pertinent family history parents siblings 2", "pdf_field_type": "Text", "reading_order": 11 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 36, "t": 574.8, "r": 572.4, "b": 561.96 }, "text": "Accidents/injuries: Major surgeries: Pertinent family history (parents & siblings [3]", "field_kind": "text", "label": "Accidents/injuries: Major surgeries: Pertinent family history (parents & siblings [3]", "pdf_field_name": "Accidentsinjuries Major surgeries Pertinent family history parents siblings 3", "pdf_field_type": "Text", "reading_order": 12 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 36, "t": 533.88, "r": 567, "b": 521.64 }, "text": "Medications", "field_kind": "text", "label": "Medications", "pdf_field_name": "Medications", "pdf_field_type": "Text", "reading_order": 13 }, { "page": 2, "type": "TITLE", "location": { "l": 169.92, "t": 492.24, "r": 440.88, "b": 478.56 }, "text": "Physical Examination (Completed by Health Care Provider)", "reading_order": 14, "level": 2 }, { "page": 2, "type": "TEXT", "location": { "l": 34.56, "t": 465.6, "r": 568.8, "b": 451.92 }, "text": "General health: ___", "reading_order": 15 }, { "page": 2, "type": "TEXT", "location": { "l": 34.08, "t": 438.72, "r": 492.72, "b": 424.56 }, "text": "Height: ___ weight: ___ blood pressure: ___ pulse: ___", "reading_order": 16 }, { "page": 2, "type": "TEXT", "location": { "l": 34.08, "t": 411.84, "r": 501.12, "b": 398.4 }, "text": "___eyes/vision ___ears/hearing", "reading_order": 17 }, { "page": 2, "type": "TEXT", "location": { "l": 34.32, "t": 396.72, "r": 285.84, "b": 384.48 }, "text": "___ nervous system ___ circulatory system", "reading_order": 18 }, { "page": 2, "type": "TEXT", "location": { "l": 33.84, "t": 383.76, "r": 311.76, "b": 370.56 }, "text": "___musculoskeletal system", "reading_order": 19 }, { "page": 2, "type": "TEXT", "location": { "l": 34.08, "t": 383.52, "r": 133.68, "b": 371.04 }, "text": "___ digestive system", "reading_order": 20 }, { "page": 2, "type": "TEXT", "location": { "l": 357.84, "t": 411.6, "r": 497.76, "b": 397.92 }, "text": "___dental respiratory system", "reading_order": 21 }, { "page": 2, "type": "TEXT", "location": { "l": 358.08, "t": 397.2, "r": 464.4, "b": 384.72 }, "text": "___endocrine system", "reading_order": 22 }, { "page": 2, "type": "TEXT", "location": { "l": 241.44, "t": 357.36, "r": 370.32, "b": 344.88 }, "text": "Tuberculin skin test or x-ray", "reading_order": 23 }, { "page": 2, "type": "TEXT", "location": { "l": 36, "t": 331.2, "r": 503.04, "b": 318 }, "text": "Date administered: ___ Date read: ___", "reading_order": 24 }, { "page": 2, "type": "TEXT", "location": { "l": 394.08, "t": 330.72, "r": 501.12, "b": 317.76 }, "text": "Results: _____", "reading_order": 25 }, { "page": 2, "type": "TEXT", "location": { "l": 34.32, "t": 303.6, "r": 574.56, "b": 264.96 }, "text": "I certify that I have examined this individual and find him/her performing the duties of student teaching except as follows:_____", "reading_order": 26 }, { "page": 2, "type": "TEXT", "location": { "l": 34.8, "t": 232.8, "r": 185.04, "b": 222.48 }, "text": "Distributed Memory", "reading_order": 27 }, { "page": 2, "type": "TEXT", "location": { "l": 33.12, "t": 222.72, "r": 183.84, "b": 209.76 }, "text": "Printed Name\n___", "reading_order": 28 }, { "page": 2, "type": "TEXT", "location": { "l": 214.32, "t": 232.56, "r": 365.76, "b": 222.24 }, "text": "
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