Application for:
FALL
SPRING
year
year
Teacher Internship Application
Kremen School of Education and Human Development
5005 N. Maple Ave #220D M/S ED 2
Fresno CA 93740-8025
(559) 278-0232
TYPE OR PRINT CLEARLY
First Name:
Last Name:
Maiden Name:
Student ID Number:
Birth Date:
Address:
City:
Home Telephone:
Zip Code:
Work Telephone:
Cell Phone:
Fresno State E-Mail:
@mail.fresnostate.edu (REQUIRED)
*Please note: The Teacher Internship Program serves Fresno, Kings, Madera, Mariposa, Merced, and Tulare county.
1.
Do you hold a baccalaureate degree from an accredited institution?
Yes
If yes, BA/BS degree in
College/University
Cumulative GPA
2.
Are you currently admitted as a regular student at CSUF?
Yes
No
(If you were not enrolled in the university the semester prior to internship you must reapply to the university).
3.
Are you currently admitted to the Credential Program in the Kremen School of Education and Human
Development?
Yes
No
4.
Please check the credential program you are pursuing, list language in BCLAD option (if applicable), and subject
area for single subject candidates only:
Multiple Subject
Multiple Subject (BCLAD)
Hmong
Spanish
5.
Special Education:
Mild/Moderate
Moderate/Severe
Have you applied for Final Student Teaching?
Yes
6.
Single Subject
Subject Area:
No
No
Application can be found at: fresnostate.edu/kremen/applications/forms.html
Have you taken a course that fulfills the California requirements for the study of the U.S. Constitution?
Yes
No Institution:
Course
7. Indicate the status of your subject matter preparation below:
Subject Matter Competency:
CSET Exam (all sections)
Date Completed: _____________________
Completion by Coursework
Date Completed: _____________________
Please Note: Intern teaching position must be in the area of your subject matter competency.
Rev March 16
1
8.
The teacher internship training consists of two (2) consecutive semesters. Are you able to devote two semesters to
classroom teaching?
Yes
No
9.
In addition to final student teaching, during your internship year you will need to enroll in any remaining course
work leading towards completion of your credential program. Are you able to take that course work during evening
classes?
Yes
No
10. Have you completed the English Language Training (LEE 172 for SPED and Multiple Subject; LEE 157 for Single
Subject or equivalent coursework)?
Yes
No
11.
Are you currently working under contract with a school district?
Length of Service
If yes, district name:
(Do not indicate substitute position).
Yes
No
12.
Please note that the Teacher Internship Program cannot secure a teaching position for you, although it may submit
your name to participating school districts where openings may occur once you are admitted to the program. At this
time, has a public school district offered you a teacher internship position? Yes
No If yes, specify district and school site:
13.
Under the terms of the agreement between school districts and the Teacher Internship Program, you must refrain
from outside employment, except during school vacations of longer than four days. Are you willing to work
exclusively as a teacher intern?
Yes
No
14.
I authorize the Teacher Internship Program to release my phone number to school districts so they can contact
me for interview purposes
Yes
No
Preferred districts: ___________________________________________________________________
Additional Paperwork to be attached to your application:
15.
Statement of Purpose:
On a separate sheet, in narrative form, explain why you feel you can be successful as a teacher intern. Please
include teaching or job related experiences that have prepared you for a teacher internship. Three to four
paragraphs will be sufficient.
16.
Letters of Support:
Whether you are a Multiple Subject, Single Subject or Special Education candidate, you must submit two letters of
support with this application form. Please use the form at www.fresnostate.edu/internship
a.
b.
c.
The first letter will be from your most recent master teacher in initial student teaching or Field Study B
(EHD 110D/EHD 178/EHD 155A). If you are currently enrolled in EHD 110/EHD 178/EHD 155A you
may turn this intern application in immediately. Your letter of recommendation may be turned in at the
end of the current semester.
The second letter will be from your most recent university supervisor in initial student teaching or
Field Study B (EHD 110D/EHD 178/EHD 155A). If you are currently enrolled in EHD 110/EHD
178/EHD 155A you may turn this intern application in immediately. Your letter of recommendation
may be turned in at the end of the current semester.
If you have waived initial student teaching (EHD 110D/EHD 155A) please provide two letters, one from
a site administrator and one from an educator working at your school site who has observed your
teaching.
Please Note: Letters of Support may be hand delivered by you (the applicant) if enclosed in a sealed envelope
with a signature across the seal. Letters can also be emailed directly to the internship office, please contact the
TIP office for email address.
Rev
March 16
2
REQUIRED FOR ALL SINGLE SUBJECT STUDENTS
Yes
REQUIRED FOR ALL MULTIPLE SUBJECT STUDENTS
All Multiple Subject students must have an IEP in place prior to beginning an internship. Students can meet with your current
University Supervisor or another faculty member to set it up.
2nd phase
I will be going in to my:
3rd phase
I understand that an IEP must be set in place prior before I can sign a contract with a district and begin my internship.
Signature: _____________________________________________
Date: _______________
REQUIRED FOR ALL EDUCATION SPECIALIST STUDENTS
Recommendation from Special Education Coordinator
Special Education Coordinator’s Name (Please Print) __________________________________
Special Education Coordinator’s Signature __________________________________________
18.
Date ___________
Indicate your course work status on the table below.
Note: You must maintain a cumulative 3.00 GPA in the basic credential courses.
If you have completed or are enrolled in prerequisite credential courses, specify semester of successful completion
(indicate in progress if that is the case).
Prerequisite Coursework for the Teacher Internship Program
Special Education
Multiple Subject
Course
EHD 50 (or waived) CI 100
PHASE 1
CI 171
LEE 172
LEE 173
EHD 174
EHD 174A
Semester
Completed
Course
SPED 120
EHD 50 (or waived) CI 100
PHASE 1
LEE 172
LEE 173
EHD 178
EHD 178A
SPED 130
SPED 145 or 146 Semester
Completed
Single Subject
Course
EHD 50 (or waived) CI 149
CI 151
LEE 157
CI 152
EHD 155A
EHD 154A
Semester
Completed
I certify that all information I have provided in this application is accurate and I understand the
requirements of the Teacher Internship Program.
Signature
Rev
March 16
Date
3