USI Student Teaching Application for Term:
Directions to the teacher candidate: To complete this application, you will need a copy of the Directions, your DARS or DegreeWorks report, and
a program sheet from your major. After the application has been approved by your advisor, you should print one copy of pages “A” and “B.” These
pages will be kept in the Teacher Education office for our records. You must print three copies of pages 1 and 2 of the application and your essay
responses. These pages are circulated to school officials for placement purposes.
Candidate Information
Name:
Student ID #
Date of Admission to Teacher Education:
Term/Year You Plan to Student Teach:
Date of Birth:
USI Email:
Major(s):
Minor(s):
Local Address:
Local Phone:
Permanent Phone:
Permanent
Address:
USI Hours Completed:
USI GPA:
Transfer Hours Completed:
List the schools from which you graduated.
School Name, City, State
Year
Elementary or K-8
Middle School/Jr. High
High School
Community College
or University
List your preferences of IN and IL school corporations/districts within a 50 mile radius of campus for your student teaching assignment. If you prefer the
Evansville Diocese schools, list the cities.
Corporation or District
City or County
Do you have any relatives who attend or are employed by any K-12 school locally or in the corporations you listed above? If so, list those schools.
Have you ever been a student in a teacher education program,
other than at USI?
YES
NO
Are you currently employed by any school corporation in any capacity?
YES
NO
A
Areas of Licensure
P-3
K-6
5 - 12
List subject area(s):
P – 12
List subject area(s):
List the following information about your three most involved field experiences:
Duties in Field Experience:
Teacher:
School:
Grade:
Term/Year:
Duties in Field Experience:
Teacher:
School:
Grade:
Term/Year:
Duties in Field Experience:
Teacher:
School:
Grade:
Term/Year:
Remaining Coursework
In the chart below, list the courses that you have left to complete before student teaching. Organize them by the semester you intend to take them. Type
the correct year in the box next to term name. Include course abbreviation, number, and 1-2 word, abbreviated title, as in BIOL 105: Intro Biol. Do not
include the synthesis course or student teaching courses.
SPRING
Courses with brief titles
SUMMER
Courses with brief titles
FALL
Courses with brief titles
Note to Advisors: Pages A and B are internal documents which are kept in the office of student teaching. The remaining pages are external documents which are
sent to local schools for placement. Your signature indicates that this candidate meets the department requirements and standards, including admission to teacher
education, a 2.75 GPA in all licensure areas (all teaching majors and teaching minors), and a 2.75 GPA overall. It also indicates that these papers are ready for
external review. Please list the candidate’s GPA in all licensure areas:
Major(s): _________________________________________________________________________ Major(s) GPA: _______________________________
Minor(s): _________________________________________________________________________ Minor(s) GPA: _______________________________
Advisor’s Signature
Date
B
University of Southern Indiana
Department of Teacher Education
8600 University Boulevard
Evansville, Indiana 47712
Phone 812.465.7024
Student Teaching Application for Term:
Name:
USI Email:
Major(s):
Minor(s):
Permanent Address:
Phone:
List the Schools From Which You Graduated (School Name, City, State)
Year
Elementary
or K-8
Middle School
or Jr. High
High School
College or
University
Check Areas of Licensure
P-3
K-6
5 - 12
List subject area(s):
P - 12
List subject area(s):
Reflective Essay Questions: Respond to each of the following questions/writing prompts in essay form on a separate sheet of paper. The length
of your answers should be sufficient to address the questions while giving the reader a clear understanding of your preparation and expectations
for student teaching. Type each prompt in bold font followed by your response in plain font. The essays should be single-spaced, and all four
responses must fit on one piece of paper. Remember to proofread your answers carefully.
1. Describe your educational background and your preparation as a teacher candidate.
2. What special interests, skills, or experiences (e.g. sports, drama, volunteer work, employment, travel, etc.)
do you bring to the school or the classroom?
3. What factors influenced you to pursue a career in teaching?
4. What do you consider the three most important attributes of an effective teacher?
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Academic Preparation
Every course required for your degree must be listed on this page. For any course that is not complete, including the current semester, list the semester of
enrollment. Indicate the subject, course number, brief title, and the grade you earned or semester you plan to enroll in the course.
Courses from the University Core Curriculum
Courses from the Major / Minor
Course Subject, Number, Brief Title
Example: ENG 101: Composition I
Grade Earned
or Term of
Enrollment
Course Subject, Number, Brief Title
Grade Earned or
Term of Enrollment
This candidate has been recommended for student teaching by his or her academic advisor. The candidate meets all requirements for student teaching.
Mrs. Joyce Rietman, Director of Advanced Clinical Experience and Co-Teaching
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