===== PAGE 1 ===== ## Kentucky State University School of Education MASPE Student Teaching Application for Admission Submit this Application for Admission, as part of your complete application packet, by February 1 for fall admission or by September 1 for spring admission. All requirements must be met by the application deadline. Admission decisions are made by the Teacher Education Committee the semester prior to the student teaching/practicum semester. ## Applicant Information Candidate: ___ Date of application: ___ Student ID: ___ GPA: ___ Telephone number(s): ___ Preferred mailing address: ___ Undergraduate major: ___ Date of admission to TEP: ___ Remaining ESP courses (attach Student Guide Sheet): ___ If Certified: Teacher certification (date, field): ___ Student teaching (dates, district, school, classroom setting, Cooperating Teacher): ___ KTIP (dates, district, school, classroom setting, Resource Teacher): ___ Provide dates and copies to verify the following: Praxis II exam date(s) & score(s): ___ Federal criminal history report: _____ NEA membership year: _____ Medical exam with TB test (date): _____ Signed & dated Professional Code of Ethics for Kentucky School Certified Personnel (attached): ___ Signed & dated Character and Fitness statement (attached): _____ Employer: ___ Address: Official job title: ___ Dates of employment in this position: ___ Job responsibilities: ___ Supervisor: Name: _____ E-mail: _____ Title: _____ Telephone: _____ ===== PAGE 2 ===== # Past Employment Employer:_____ Address: ___ Official job title: Dates of employment: ___ Job responsibilities: ___ Supervisor Name: _____ Job Title: _____ E-mail: _____ Telephone: _____ ***** Employer:___ Address: ___ Official job title: ___ Dates of employment: ___ Job responsibilities: ___ Supervisor Name: _____ Job Title: _____ E-mail: _____ Telephone: _____ ***** Employer:_____ Address: ___ Official job title: Dates of employment: ___ Job responsibilities: ___ Supervisor Name: _____ E-mail: _____ Job Title: _____ Telephone: _____ ===== PAGE 3 ===== ## Applicants to Student Teaching Student teachers must complete one term in an elementary school and the other term in a middle school or high school. In order to assist with your own placement, please propose four options: two elementary schools, one middle school, and one high school. ## Elementary School #1 School district: ___ School: ___ Accreditation/Accrediting Body: ___ School population (#): ___ Principal: _____ Telephone: _____ Principal's e-mail: ___ ## Elementary School #2 School district: _____ School: Accreditation/Accrediting Body: _____ School population (#): _____ Principal: _____ Telephone: _____ Principal's e-mail: ___ ## Middle School School district: _____ School: _____ Accreditation/Accrediting Body: School population (#): Principal: _____ Telephone: _____ Principal's e-mail: ___ ## High School School district: _____ School: _____ Accreditation/Accrediting Body: ___ School population (#): ___ Principal: _____ Telephone: _____ Principal's e-mail: ___ Student Teacher Applicant's Statement: I verify that the information in this application is current and accurate. Applicant's signature: _____ Date: _____ ===== PAGE 4 ===== # Applicants to Alternative Certification Practicum ONLY ## School Information School district: School: ___ School address: ___ Principal: ___ School population: _____ Telephone: _____ Gender and Ethnicity (number of students) # Females: ___ # Males: ___ White: ___ Black/African American: ___ American Indian/Alaska Native: ___ Asian: ___ Hispanic/Latino Origin: ___ Native Hawaiian/Other Pacific Islander: ___ Multiracial: ___ Students who qualify for free or reduced meals: ___ 504 Plans: ___ IEPs/IFSPs: ___ GSSPs: ___ ELL: ___ Behavior Plans: ___ ## Classroom Information Grade(s): ___ Class enrollment: ___ Content area(s): ___ Gender and Ethnicity (number of students) # Females: ___ # Males: ___ White: ___ Black/African American: ___ American Indian/Alaska Native: ___ Asian: ___ Hispanic/Latino Origin: ___ Native Hawaiian/Other Pacific Islander: ___ Multiracial: ___ Students who qualify for free or reduced meals: ___ 504 Plans: ___ IEPs/IFSPs: ___ GSSPs: ___ ELL: ___ Behavior Plans: ___ Alternative Certification Applicant's statement: I verify that the information in this application is current and accurate. I further verify that I am employed full-time as a Special Education Teacher at this site. Applicant's signature: ___ Date: ___ ## Principal's statement: I verify that this applicant is employed full-time as a Special Education Teacher at this site and that he or she has my permission and support to complete his or her alternative certification practicum here, during the next academic semester (fall or spring). Principal's signature: Date: ===== PAGE 5 ===== Necessity, Function, and Conformity: KRS 161.028 requires that the Education Professional Standards Board develop a professional code of ethics. This administrative regulation establishes the code of ethics for Kentucky school certified personnel and establishes that violation of the code of ethics may be grounds for revocation or suspension of Kentucky certification for professional school personnel by the Education Professional Standards Board. ### Section 1. Certified personnel in the Commonwealth: (1) Shall strive toward excellence, recognize the importance of the pursuit of truth, nurture democratic citizenship, and safeguard the freedom to learn and to teach; (2) Shall believe in the worth and dignity of each human being and in educational opportunities for all; (3) Shall strive to uphold the responsibilities of the education profession, including the following obligations to students, to parents, and to the education profession: ## (a) To Students: 1. Shall provide students with professional education services in a nondiscriminatory manner and in consonance with accepted best practice known to the educator; 2. Shall respect the constitutional rights of all students; 3. Shall take reasonable measures to protect the health, safety, and emotional well-being of students; 4. Shall not use professional relationships or authority with students for personal advantage; 5. Shall keep in confidence information about students which has been obtained in the course of professional service, unless disclosure serves professional purposes or is required by law; 6. Shall not knowingly make false or malicious statements about students or colleagues; 7. Shall refrain from subjecting students to embarrassment or disparagement; and 8. Shall not engage in any sexually related behavior with a student with or without consent, but shall maintain a professional approach with students. Sexually related behavior shall include such behaviors as sexual jokes; sexual remarks; sexual kidding or teasing; sexual innuendo; pressure for dates or sexual favors; inappropriate physical touching, kissing, or grabbing; rape; threats of physical harm; and sexual assault. ## (b) To Parents: 1. Shall make reasonable effort to communicate to parents information which should be revealed in the interest of the student; ===== PAGE 6 ===== 2. Shall endeavor to understand community cultures and diverse home environments of students; 3. Shall not knowingly distort or misrepresent facts concerning educational issues; 4. Shall distinguish between personal views and the views of the employing educational agency; 5. Shall not interfere in the exercise of political and citizenship rights and responsibilities of others; 6. Shall not use institutional privileges for private gain, for the promotion of political candidates, or for partisan political activities; and 7. Shall not accept gratuities, gifts, or favors that might impair or appear to impair professional judgment, and shall not offer any of these to obtain special advantage. ## (c) To the Education Profession: 1. Shall exemplify behaviors which maintain the dignity and integrity of the profession; 2. Shall accord just and equitable treatment to all members of the profession in the exercise of their professional rights and responsibilities; 3. Shall keep in confidence information acquired about colleagues in the course of employment, unless disclosure serves professional purposes or is required by law; 4. Shall not use coercive means or give special treatment in order to influence professional decisions; 5. Shall apply for, accept, offer, or assign a position or responsibility only on the basis of professional preparation and legal qualifications; and 6. Shall not knowingly falsify or misrepresent records of facts relating to the educator's own qualifications or those of other professionals. Section 2. Violation of this administrative regulation may result in cause to initiate proceedings for revocation or suspension of Kentucky certification as provided in KRS 161.120 and 704 KAR 20:585. (21 Ky.R. 2344; eff. 5-4-95; recodified from 704 KAR 20:680, 7-2-2002.) Printed Name: _____ Signature: _____ Date: _____ ===== PAGE 7 ===== # SECTION III. CHARACTER AND FITNESS (This form must be completed with each certification application and submitted to the Education Professional Standards Board, Division of Certification, 100 Airport Road, 3rd Floor, Frankfort, KY 40601, (502) 564-4606, (888) 598-7667, or www.Kyepsb.net) Name: ___ Social Security Number: ___ Address: ___ (Street) (City) (State) (Zip Code) Telephone Number: ( ) Answer each question by circling "yes" or "no." If you answer "yes" to any question, you must submit a full explanation using a separate sheet of paper. If you have ever held, or currently hold a professional certificate, license, credential, or other document issued to you by any jurisdiction (other than Kentucky) within the United States or abroad, enclose a copy of the certificate(s) or provide the following: State or Jurisdiction ___ Certificate Number ___ Type ___ Issue Date ___ Expiration Date ___ 1. Have you ever had a professional certificate, license, credential, or any document issued to you for practice denied, suspended, revoked, or voluntarily surrendered? 2. Are you currently being reviewed or investigated for purposes of such action as stated in #1 or is such action pending? 3. Have you ever been dismissed, resigned, released, or asked to resign/retire or discharged from a professional position or military service for immorality, incompetence, willful neglect of duty, misconduct, or presenting false information toward obtaining the position? 4. Is any such action as stated in #3 pending? Yes No 5. Have you ever been convicted of a felony or misdemeanor (other than a moving traffic violation), been found guilty, or entered a plea of nolo contendere (no contest), even if adjudication was withheld, in Kentucky or any other state? 6. If you indicated "yes" to any items, #1 through #6, has that action been reviewed. Yes No by the Education Professional Standards Board? (Date of Review) I affirm and declare that all information given by me on this form is true, and correct, and complete to the best of my knowledge. I understand that any misrepresentation of facts, by omission or addition, may result in the denial or revocation of my teaching certificate. Further, I understand that KRS 161.120 provides that a teaching certificate may be revoked at any time upon determination that false information was presented toward obtaining a teaching certificate. I declare that I understand the standard for personal and professional conduct expected of a professional educator in Kentucky. I further certify that I have read and examined the CODE OF ETHICS (page 4) applicable to school personnel, understand its provisions, and agree to abide by its terms during the course of my career as a professional educator. SIGNATURE___ DATE ___