For department use only:
EDUC 160 CRN # _________________
EDUC 160 LAB CRN # ______________
Education Department
Education 160 Study of the School Student Information Form
o
o
o
I have both my Ohio & FBI Background Check on File in the Education Department
OH Exp Date: __________ FBI Exp Date: _________ Fld Data Coor Intls: ________
I have recently had my Ohio/FBI Background Checks Processed on (approximate
date)______________________________ and have asked the results be sent to the
Education Department.
I am aware of the need to have an Ohio & FBI Background Check on File in the
Education Department Prior to Any Education Course Field Experience and that this
process may take as long as 3-5 weeks and any delay in receipt of these checks could
result in my not being placed in the field and thus impact my success and final grade in
the course.
I understand the responsibilities of the Otterbein Teacher Candidate to represent the Department in a professional manner and
have read the requirements for enrollment in the course and have received the EDUC 160 brochure given to me upon
permission to enroll.
____________________________________________________________
Signature of Candidate
Date: _____________________________
Student Information
Candidate Information: (*Please use the address to which you would prefer any correspondence be mailed.)
Student
Student ID
Name
Address *
Phone
o Cell
City
Preferred
Email
address
(√ If Otterbein)
State
Zip
Advisor
Transportation*
Check all that
apply.
I have a
car
I can
take (#)
riders
I live On
Otterbein’s
Campus
I live Off
Campus
I will be
commuting from:
I have no
transportation
*If transportation is unavailable to you, please let your supervisor know immediately so appropriate accommodations may be made.
Teaching Area
Teaching Area (Tentative) Check areas of desired licensure, listing specific concentration and/or teaching area(s) you are planning to
pursue:
Early and Middle Childhood Only
Adolescence to Young Adult (7-12)
o Early Childhood (PK-3) (1 Concentration Area)
And
Or
Multi-Age Only (Teaching Areas, Select All That Apply) (PKo Middle Childhood (4-9) (2 Concentration Areas)
12)
Concentration Areas
AYA (7-12)
Multi-Age (PK-12)
o Early Childhood Generalist
(2010 Early only)
o French (Early only)
o Intervention Specialist (Early
only)
o Language Arts (Early &
Middle)
o Deaf Community (Early only)
o Mathematics (Early & Middle)
o Reading (Early only)
o Science (Early & Middle)
o Social Studies (Early &
Middle)
o Spanish (Early only)
o Specialized Content (2010
Early only)
o Psych/Soc (Early CSCC only)
o
o
o
o
o
Language Arts
Life Sciences
Mathematics
Physical Sciences
Social Studies
o
o
o
o
o
o
French
Health
Music
Physical Education
Spanish
Visual Arts
Extracurricular Activities (Sports/Organizations)
Please list any organization
or sports you are currently
involved in:
Educational Background
High School Attended
(Name)
School District (City, State)
Previous Colleges
Honors, Activities
(Include Extracurricular)
Employment
Current Employer or
“Not Applicable”
Location of Employment
Weekly Work Schedule
Professional Skills
List any professional skills
you possess that might be
helpful in your placement.
Brief Personal Statement
Why do you think you
would be successful in a
teaching career?
What
inspires you to pursue this
career?
What is your tentative goal
in education? (Band
Instructor, Intervention
Specialist, Kindergarten
Teacher)
Additional information you
may wish to provide: