College of Liberal Arts and Sciences

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College of Liberal Arts & Sciences Educator Licensure Programs
Office of Secondary School Partnerships and Clinical Experiences
(815) 753-0325
Application for Final Clinical Experience/Student Teaching
DEMOGRAPHIC INFORMATION
Student Name
Fall
Spring Year:
Student Teaching Semester & Year
Discipline
Z-ID
In what town will you reside during your student teaching semester?
Please note that the Placement Office will attempt to place you in a district within 60 miles of this town. Transportation is not provided.
BACKGROUND EXPERIENCES
Please answer the following questions in order to ensure a diverse clinical experience and to avoid conflicts of interest.
Middle School from which you graduated
City
State
High School from which you graduated
City
State
ILAS 201 Middle School Placement
ILAS 201 High School Placement
ILAS 301 Middle School Placement
ILAS 301 High School Placement
In which Illinois schools (if any) do you have a close friend and/or relative employed, enrolled, or serving as a school board member?
PLACEMENT PREFERENCES
No preference
Middle School/Jr. High
Check grade level preference
High School
No preference
100-499
500-1499
Check student enrollment preference
1500+
Indicate the geographic locations in which you would prefer to do your student teaching. Identify first, second, and third choices. Please note that not all of the
above geographical locations can be serviced in a given semester, so please consider your second and third choices carefully so that we can take your
preferences as much as possible into account when making your placement. Please be advised that we may need to seek placements other than those indicated.
Additional Notes (for Department/CLAS use only):
Choice
Locations
Lake Zurich, Libertyville, Lincolnshire, Mundelein, Wauconda
Arlington Heights, Barrington, Palatine, Rolling Meadows, Wheeling
Woodstock, Harvard, Johnsburg, McHenry
Algonquin, Cary, Crystal Lake, Dundee, Hoffman Estates
Burlington, Hampshire, Huntley, Marengo
Addison, Carol Stream, Elgin, Roselle, Schaumburg, Streamwood
Aurora, Batavia, South Elgin, Geneva, Kaneland, St. Charles
Downers Grove, Lombard, Naperville, Villa Park, West Chicago, Wheaton
DeKalb, Genoa-Kingston, Hinckley, Shabbona, Sycamore
Freeport, Byron, Stillman Valley, Oregon
Dixon, Sterling, Rock Falls, Polo
Yorkville, Oswego, Sandwich, Plano
Plainfield, Bolingbrook, Romeoville
Des Plaines, Park Ridge, Niles, Chicago (Northside only)
Rockford, Rockton, Belvidere
ADDITIONAL REQUIREMENTS
Have you passed and turned in a copy of your TAP test?
TAP Passed
Have you included your negative TB test results in this application?
ACT/TAP Substitution
YES
Date Taken:
Expiration Date:
You must also include a FERPA form with original signature. Access the FERPA Form here: http://niu.edu/tcert/ferpa_form.pdf
I understand that transportation is my responsibility, and that I must satisfy any pre-requisites set by my program before I begin in my placement.
Signature of Student Teaching Applicant
Date
Verified by Signature of Teaching Certification Coordinator
Date
INSERT FERPA FORM ON THIS PAGE
INSERT TB TEST ON THIS PAGE
College of Liberal Arts & Sciences Educator Licensure Programs
Office of Secondary School Partnerships and Clinical Experiences
(815) 753-0325
Student Teacher Personal Data Sheet for Cooperating Teachers
DEMOGRAPHIC INFORMATION
Fall
Student Name
Discipline
Address where you will reside during student teaching:
Street
Spring Year:
Student Teaching Semester/Year
City
Telephone
Z-ID
Zip
NIU E-mail Address
Please note: Your NIU e-mail will be the ONLY e-mail address that will be used to send you information regarding student teaching placements and other important
updates. It is your responsibility to check this email frequently to ensure receipt of emails as well as to keep this account from exceeding capacity.
EDUCATION
High School Attended
City and State
Date of Graduation
Colleges or universities attended in addition to NIU and degree completed, if applicable:
Institution Attended
Degree Earned
Date of Graduation
Institution Attended
Degree Earned
Date of Graduation
WORK EXPERIENCE
Previous classroom teaching experience, if any:
Paid summer and part-time employment as camp counselor, YMCA instructor, tutor, or similar group leadership experiences:
Unpaid leadership experience such as tutoring, scout leader, church school teacher, etc.:
Additional work experience:
Special abilities, interests, hobbies, awards, distinctions:
Special disabilities or limitations, if any, which you wish to call to the attention of your cooperating teacher or university supervisor:
PROGRAM, DEGREE, & LICENSURE INFORMATION
Date of Admission to NIU
Date of Expected Program Completion
Teaching Field/Major
Additional Subject Area Endorsements
Degree Sought
Total semester hours taken in your major
Hours taken at NIU in your major
MAJOR COURSE WORK (completed by the start of student teaching)
COURSE TITLE
COURSE #
INSTITUTION
Current Overall GPA
Current Discipline GPA
Hours taken outside NIU in your major
YEAR
HOURS
GRADE
YEAR
HOURS
GRADE
YEAR
HOURS
GRADE
EDUCATION COURSE WORK (completed by the start of student teaching)
COURSE TITLE
COURSE #
INSTITUTION
ENDORSMENT COURSE WORK (completed by the start of student teaching)
COURSE TITLE
COURSE #
INSTITUTION
PLACEMENT APPLICATION STATEMENT:
Compose an updated personal statement of about 1-2 pages double-spaced, directed towards your prospective cooperating teacher. Use
professional language, as you would for a job application. Include examples from your previous observations in schools (but do not
mention specific schools or districts). Consider these questions as you write: What are some of your strengths as a teacher of your subject
area-- what do you bring to the table? What is most important to you when planning and teaching classes? The statement should focus on
teaching, but can also shed some light on you as a person, your professional ambitions, and your interests in activities.
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