[ { "page": 1, "items": [ { "page": 1, "type": "TITLE", "location": { "l": 141.12, "t": 744, "r": 470.64, "b": 691.44 }, "text": "Kentucky State University\nSchool of Education Human Development and Consumer Sciences\nAdmission to Educator Preparation Program (EPP) Application\n(Please print)", "reading_order": 0, "level": 1 }, { "page": 1, "type": "TEXT", "location": { "l": 34.08, "t": 678.72, "r": 409.68, "b": 666.96 }, "text": "Candidate: ___", "reading_order": 1 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 84.48, "t": 691.32, "r": 408.24, "b": 669.48 }, "text": "Candidate", "field_kind": "text", "label": "Candidate", "pdf_field_name": "Candidate", "pdf_field_type": "Text", "reading_order": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 45.12, "t": 667.92, "r": 411.6, "b": 659.76 }, "text": "Last First Middle Maiden\nDate: _____", "reading_order": 3 }, { "page": 1, "type": "TEXT", "location": { "l": 430.56, "t": 678.48, "r": 564.72, "b": 666.96 }, "text": "Date:", 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287.04, "t": 636, "r": 387.12, "b": 627.12 }, "text": "State Zip Code", "reading_order": 10 }, { "page": 1, "type": "TEXT", "location": { "l": 430.56, "t": 647.04, "r": 564.96, "b": 635.04 }, "text": "Tel.:", "reading_order": 11 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 451.68, "t": 659.76, "r": 563.76, "b": 637.68 }, "text": "Tel", "field_kind": "text", "label": "Tel", "pdf_field_name": "Tel", "pdf_field_type": "Text", "reading_order": 12 }, { "page": 1, "type": "TEXT", "location": { "l": 35.52, "t": 618.24, "r": 564.24, "b": 606.72 }, "text": "Permanent Address: ___", "reading_order": 13 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 122.88, "t": 627.72, "r": 418.56, "b": 608.4 }, "text": "Permanent Address", "field_kind": "text", "label": "Permanent Address", "pdf_field_name": "Permanent Address", "pdf_field_type": "Text", "reading_order": 14 }, { "page": 1, "type": "TEXT", "location": { "l": 431.04, "t": 618.24, "r": 565.44, "b": 606.24 }, "text": "Tel.:", "reading_order": 15 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 451.68, "t": 630.48, "r": 563.76, "b": 608.4 }, "text": "Tel", "field_kind": "text", "label": "Tel", "pdf_field_name": "Tel_2", "pdf_field_type": "Text", "reading_order": 16 }, { "page": 1, "type": "TEXT", "location": { "l": 33.6, "t": 614.64, "r": 417.36, "b": 598.08 }, "text": "Permanent Address: ___\nStreet City State Zip Code\nTel.: ___", "reading_order": 17 }, { "page": 1, "type": "TEXT", "location": { "l": 34.56, "t": 589.2, "r": 571.44, "b": 576.96 }, "text": "E-mail Address: ___", "reading_order": 18 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 102.84, "t": 598.44, "r": 569.04, "b": 579 }, "text": "E-mail Address", "field_kind": "text", "label": "E-mail Address", "pdf_field_name": "Email Address", "pdf_field_type": "Text", "reading_order": 19 }, { "page": 1, "type": "TEXT", "location": { "l": 34.32, "t": 565.92, "r": 539.76, "b": 553.68 }, "text": "KSU Student ID#: ___ Date of Birth: ___ / ___ / ___ Gender: ___", "reading_order": 20 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 109.2, "t": 577.92, "r": 270.36, "b": 555.84 }, "text": "KSU Student ID", "field_kind": "text", "label": "KSU Student ID", "pdf_field_name": "KSU Student ID", "pdf_field_type": "Text", "reading_order": 21 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 323.64, "t": 577.92, "r": 350.52, "b": 555.84 }, "text": "Date of Birth", "field_kind": "text", "label": "Date of Birth", "pdf_field_name": "Date of Birth", "pdf_field_type": "Text", "reading_order": 22 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 356.04, "t": 577.92, "r": 378.48, "b": 555.84 }, "text": "undefined", "field_kind": "text", "label": "undefined", "pdf_field_name": "undefined", "pdf_field_type": "Text", "reading_order": 23 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 381.96, "t": 577.92, "r": 417.96, "b": 555.84 }, "text": "undefined", "field_kind": "text", "label": "undefined", 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"CheckBox", "reading_order": 42 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 180.72, "t": 469.08, "r": 191.4, "b": 458.4 }, "text": "Junior", "field_kind": "checkbox", "label": "Junior", "pdf_field_name": "Junior", "pdf_field_type": "CheckBox", "reading_order": 43 }, { "page": 1, "type": "TEXT", "location": { "l": 287.28, "t": 470.4, "r": 561.12, "b": 456.72 }, "text": "☐ Senior ☐ Full-Time ☐ Part-Time", "reading_order": 44 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 288.72, "t": 469.08, "r": 299.4, "b": 458.4 }, "text": "Senior", "field_kind": "checkbox", "label": "Senior", "pdf_field_name": "Senior", "pdf_field_type": "CheckBox", "reading_order": 45 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 432.72, "t": 469.08, "r": 443.4, "b": 458.4 }, "text": "Full-Time", "field_kind": "checkbox", "label": "Full-Time", "pdf_field_name": "FullTime", "pdf_field_type": "CheckBox", "reading_order": 46 }, { "page": 1, "type": "TEXT", "location": { "l": 503.28, 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"type": "TEXT", "location": { "l": 35.28, "t": 424.08, "r": 546.48, "b": 412.08 }, "text": "Grade Point Average 2.75 OR 3.0 in last 30 hours: ___ Credit Hours completed: ___ (min. 45)", "reading_order": 52 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 240.6, "t": 436.32, "r": 357.24, "b": 414.24 }, "text": "Grade Point Average 2.75 OR 3.0 in last 30 hours", "field_kind": "text", "label": "Grade Point Average 2.75 OR 3.0 in last 30 hours", "pdf_field_name": "Grade Point Average 275 OR 30 in last 30 hours", "pdf_field_type": "Text", "reading_order": 53 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 460.44, "t": 436.32, "r": 505.32, "b": 414.24 }, "text": "CreditHours completed", "field_kind": "text", "label": "CreditHours completed", "pdf_field_name": "CreditHours completed", "pdf_field_type": "Text", "reading_order": 54 }, { "page": 1, "type": "TEXT", "location": { "l": 35.52, "t": 401.04, "r": 573.36, "b": 389.28 }, "text": "Semester/Year of Admission to KSU: _____ Estimated Semester and Year of Graduation: _____", "reading_order": 55 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 187.2, "t": 413.16, "r": 267.84, "b": 391.08 }, "text": "Semester/Year of Admission to KSU", "field_kind": "text", "label": "Semester/Year of Admission to KSU", "pdf_field_name": "SemesterYear of Admission to KSU", "pdf_field_type": "Text", "reading_order": 56 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 454.8, "t": 413.16, "r": 571.32, "b": 391.08 }, "text": "Estimated Semester and Year of Graduation", "field_kind": "text", "label": "Estimated Semester and Year of Graduation", "pdf_field_name": "Estimated Semester and Year of Graduation", "pdf_field_type": "Text", "reading_order": 57 }, { "page": 1, "type": "TEXT", "location": { "l": 33.6, "t": 377.76, "r": 182.88, "b": 366.24 }, "text": "Letter Grade Achieved (C or better):\nENG 101 ___; ENG 102 ___; EDU 202 ___ AND EDU 203 ___ OR", "reading_order": 58 }, { "page": 1, "type": "TEXT", "location": { "l": 214.08, "t": 377.76, "r": 567.84, "b": 366.24 }, "text": "ENG 101 ___; ENG 102 ___; EDU 202 ___ AND EDU 203 ___ OR", "reading_order": 59 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 253.44, "t": 390, "r": 273.36, "b": 367.92 }, "text": "ENG 101", "field_kind": "text", "label": "ENG 101", "pdf_field_name": "ENG 101", "pdf_field_type": "Text", "reading_order": 60 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 325.44, "t": 390, "r": 345.36, "b": 367.92 }, "text": "ENG 102", "field_kind": "text", "label": "ENG 102", "pdf_field_name": "ENG 102", "pdf_field_type": "Text", "reading_order": 61 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 397.32, "t": 390, "r": 417.24, "b": 367.92 }, "text": "EDU 202", "field_kind": "text", "label": "EDU 202", "pdf_field_name": "EDU 202", "pdf_field_type": "Text", "reading_order": 62 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 501.84, "t": 390, "r": 546.6, "b": 367.92 }, "text": "EDU 203", "field_kind": "text", "label": "EDU 203", "pdf_field_name": "EDU 203", "pdf_field_type": "Text", "reading_order": 63 }, { "page": 1, "type": "TEXT", "location": { "l": 213.6, "t": 353.04, "r": 463.92, "b": 341.28 }, "text": "IECE Majors:: CDF 203 ____ AND CDF 204 ____ OR", "reading_order": 64 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 323.88, "t": 365.52, "r": 348.84, "b": 343.44 }, "text": "CDF 203", "field_kind": "text", "label": "CDF 203", "pdf_field_name": "CDF 203", "pdf_field_type": "Text", "reading_order": 65 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 417.12, "t": 365.52, "r": 441.96, "b": 343.44 }, "text": "AND CDF 204", "field_kind": "text", "label": "AND CDF 204", "pdf_field_name": "AND CDF 204", "pdf_field_type": "Text", "reading_order": 66 }, { "page": 1, "type": "TEXT", "location": { "l": 213.36, "t": 329.04, "r": 498.24, "b": 316.8 }, "text": "MUSIC Education Majors: EDU 202____ AND MUE 203_____", "reading_order": 67 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 361.32, "t": 341.16, "r": 396.12, "b": 319.08 }, "text": "MUSIC Education Majors: EDU 202", "field_kind": "text", "label": "MUSIC Education Majors: EDU 202", "pdf_field_name": "MUSIC Education Majors EDU 202", "pdf_field_type": "Text", "reading_order": 68 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 461.52, "t": 341.16, "r": 496.44, "b": 319.08 }, "text": "AND MUE 203", "field_kind": "text", "label": "AND MUE 203", "pdf_field_name": "AND MUE 203", "pdf_field_type": "Text", "reading_order": 69 }, { "page": 1, "type": "TEXT", "location": { "l": 33.6, "t": 305.76, "r": 568.56, "b": 281.04 }, "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": 70 }, { "page": 1, "type": "TEXT", "location": { "l": 52.32, "t": 267.12, "r": 432.96, "b": 228.48 }, "text": "Test Score requirement for admission to EPP: Core Academic Skills for Educators Test (CC)\nMinimum Score Requirement: Reading (min. 156); Writing (min. 162); Math (min. 150).\nProvide copy to the School of Education office.", "reading_order": 71 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 54.1424, "t": 266.529, "r": 59.9434, "b": 259.277 }, "text": "", "field_kind": "checkbox", "label": "", "pdf_field_name": "Check Box17", "pdf_field_type": "CheckBox", "reading_order": 72 }, { "page": 1, "type": "TEXT", "location": { "l": 51.84, "t": 225.6, "r": 550.08, "b": 214.08 }, "text": "Three Completed Assessment of Professional Dispositions, Values, & Behaviors form (1 filled out by you and 2 others)", "reading_order": 73 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 53.659, "t": 223.505, "r": 59.46, "b": 216.253 }, "text": "", "field_kind": "checkbox", "label": "", "pdf_field_name": "Check Box18", "pdf_field_type": "CheckBox", "reading_order": 74 }, { "page": 1, "type": "TEXT", "location": { "l": 51.12, "t": 210.96, "r": 356.64, "b": 200.16 }, "text": "25 field experience hours and proof of field hours submitted to SEHD.", "reading_order": 75 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 54.1424, "t": 209.002, "r": 59.9434, "b": 201.751 }, "text": "", "field_kind": "checkbox", "label": "", "pdf_field_name": "Check Box19", "pdf_field_type": "CheckBox", "reading_order": 76 }, { "page": 1, "type": "TEXT", "location": { "l": 50.88, "t": 196.56, "r": 287.04, "b": 185.28 }, "text": "Autobiographical Sketch submitted with application.", "reading_order": 77 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 54.6258, "t": 194.983, "r": 60.4268, "b": 187.732 }, "text": "", "field_kind": "checkbox", "label": "", "pdf_field_name": "Check Box20", "pdf_field_type": "CheckBox", "reading_order": 78 }, { "page": 1, "type": "TEXT", "location": { "l": 51.36, "t": 181.92, "r": 400.8, "b": 170.4 }, "text": "Successful completion of EPP interview, scheduled by School of Education office.", "reading_order": 79 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 54.1424, "t": 179.997, "r": 59.9434, "b": 172.746 }, "text": "", "field_kind": "checkbox", "label": "", "pdf_field_name": "Check Box21", "pdf_field_type": "CheckBox", "reading_order": 80 }, { "page": 1, "type": "TEXT", "location": { "l": 33.12, "t": 157.68, "r": 577.2, "b": 60.48 }, "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": 81 }, { "page": 1, "type": "TEXT", "location": { "l": 34.08, "t": 47.52, "r": 282.24, "b": 36.24 }, "text": "Signature: _____\nDate: _____", "reading_order": 82 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 81.96, "t": 60.48, "r": 281.16, "b": 38.4 }, "text": "Signature", "field_kind": "signature", "label": "Signature", "pdf_field_name": "Signature", "pdf_field_type": "Signature", "reading_order": 83 }, { "page": 1, "type": "TEXT", "location": { "l": 322.08, "t": 47.52, "r": 492, "b": 36.24 }, "text": "Date: ___", "reading_order": 84 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 346.08, "t": 60.48, "r": 490.44, "b": 38.4 }, "text": "Date", "field_kind": "text", "label": "Date", "pdf_field_name": "Date_2", "pdf_field_type": "Text", "reading_order": 85 } ] }, { "page": 2, "items": [] } ]