6.18.13
APPLICATION FOR (CLINICAL) INTERNSHIP
Alabama A & M University
Office of Field Experiences and School Partnerships
Directions for completing application:
Applications are submitted one semester before the intended internship. March 15 (of the previous semester) is the application
deadline for the Fall internship, and September 15 (of the previous semester) is the application deadline for the Spring internship.
Type the application. Submit two copies to the Office of Field Experiences and School Partnerships (room 216 Carver
Complex).
The following items must be attached to the completed application or the application will not be accepted:
1.
2.
3.
4.
5.
6.
7.
Suitability Letter (background clearance)
Copies of passing scores on all required Praxis II examinations
Copy of approved course substitutions (if applicable)
Copy of Admission to the Teacher Education Program (TEP) Letter and Certificate With Admission Date
Unofficial transcript from Banner
Copy of curriculum checklist
Curriculum checklist completed and signed by Advisor
Semester of intended Internship:
/
Expected Date of Graduation:
(Semester)
Graduate______________
/
(Year)
(Semester)
(Year)
Undergraduate_________________ Program Major______________________
Please answer each question below, completely, and accurately.
Personal Data:
Candidate:
/
/
Title (e.g., Mr., Mrs., Ms.)
Last
Student I.D. No.:
/
First
Date of Birth:
/
Middle
/ /
Maiden
Place of Birth:
/
(month/day/year)
Marital Status:
Suffix (e.g., Jr., Sr.)
(city/state)
Number of Children:
Age(s):
Local Address:
Street/Apt/P.O. Box/Route and Box
City
State
Zip Code
Street/Apt/P.O. Box/Route and Box
City
State
Zip Code
Permanent Address:
Email address:
Permanent Telephone No.: (
Local Telephone Number: (
)
Mobile Telephone Number: (
Name of Emergency Contact Person:
Telephone Number of Emergency Contact Person: (
)
)
)
Page 2
Internship Application
Please list any health problems that may interfere with your internship (i.e., asthma, diabetes, migraine
headaches, etc.)
Language Spoken at Home:
Other Language(s) Spoken:
High School Attended:
City/State:
Colleges or Universities Attended (other than AAMU) and Degrees Received:
Academic Data:
Classification: (check one)
Graduate (5th Year)
Undergraduate (Senior)
Major:
Academic Advisor:
Departmental Chairperson:
Date of State Approved Checklist Used:
(month/day/Year)
(Attach the checklist with the application and make sure it is signed by the advisor)
Approved Departmental Course Substitution on file, if applicable:
Does not apply
(Attach a copy of the substitution form if “yes” is checked.)
Overall GPA:
Professional Studies GPA:
(check one)
Yes
No
General Studies GPA:
Teaching Field(s) GPA:
Have completed the required minimum 205 clock hours of field experiences, plus 7 hours of opening of the school
year and 7 hours of closing of the school year requirements and have submitted documentation to The Office of
Field Experiences and School Partnerships: (check one) Yes________ No________
Have taken and passed the Praxis II exam(s): (check one) Yes________
No________
Date Taken:___________________
Score:________________
Subject Area:__________________________
Date Taken:___________________
Score:________________
Subject Area:__________________________
Date Taken:___________________ Score:________________
(Attach a copy of the passed Praxis II examination scores.)
Subject Area:__________________________
Have been fingerprinted and passed the SDE background check: (check one) Yes_________
(Attach a copy of the cleared background check.)
2
No_________
Professional Organizations (Membership, e.g., SAEA):
Internship School Placement Requests:
Directions:
(Please write the name of the school(s) where the pre-clinical (methods) block were
completed, or where you are currently completing the pre-clinical field experiences.)
lst
Name of School
District
Name of School
District
2nd
Area(s) of intended certification (e.g., elementary K-6, PE P-12, Music Vocal P-12, Music Instrumental P-12, ECH
K-3, Col K-6, Col 6-12, Art P-12, Ag 6-12, FCS 6-12, Business ED 6-12, Secondary 6-12):
1st
2nd
Requests Subject(s) (if applicable):
1St
2nd
3rd
Requested Grade Level(s):
1st
2nd
3rd
3
List course(s) currently enrolled. If none, please indicate “NONE”
COURSE NUMBER AND TITLE
SEM. HRS.
List any courses left on the checklist other than courses currently enrolled in and the internship. If none,
please indicate “NONE”
COURSE NUMBER AND TITLE
SEM. HRS.
List any deficiencies including D’s, F’s, I’s. If none, please indicate “NONE.” (Do not include course(s)
currently enrolled)
COURSE NUMBER AND TITLE
GRADE
(List D’s, F’s, I’s)
4
SEM. HRS.
Name of Candidate:________________________________________ Banner I.D. No.:
Candidate’s Signature:
Date:
Name of Advisor: __________________________________________
Date:_________________
Advisor’s Signature:_________________________________________
Date:_________________
Chairperson’s Signature:______________________________________
Date:_________________
Eligibility Assessment: (completed by candidate) and advisor and signed by both candidate and advisor)
HAVE MET THE FOLLOWING REQUIREMENTS
(Check Met or Not Met)
1.
2.
3.
Undergraduate
Requirement
met
Undergraduate
Requirement
Not met
Graduate
Met
Graduate
Not
Met
NA
NA
Have record audit checklist from academic advisor (and
have attached a copy)
Have been admitted to Teacher Education
Date_________________ (and have attached a copy)
Grade Point Average of 2.50 in four areas: (Overall,
General Studies, Professional Studies and Teaching Field) for
undergraduate and grade point average of 3.0 in three areas (overall,
professional studies, and teaching field for graduate)
4.
5.
6.
7.
8.
Have approved course substitution forms for any
courses taken at another university or any courses
substituted (and have attached a copy)
Grade of “C” or better in ENG 101, ENG 102,
Professional Studies and Teaching Field Courses if
undergraduate
Have earned less than one C’s in graduate program if
graduate candidate.
Have removed I’s, D’s, F’s, if not please list course(s)
below:
Have taken all Praxis II tests and passed prior to
internship (Effective Fall 2006). If not, please list the
tests that are not passed:
5
NA
NA