SECONDARY – CHEMISTRY STUDENT TEACHING APPLICATION
PURDUE UNIVERSITY NORTH CENTRAL
EDUCATION SECTION
1401 S US 421
Westville, IN 46391
(219) 785-5485
For Office Use Only
Requirements
Staff Initials
Cumulative GPA:
Professional GPA:
Praxis II
Background Check
Signature Form:
Name:
Title, First, Middle Initial, Last
Birth Date:
Address:
Date
Street, City, State, Zip Code
Phone:
E-Mail:
Semester that you will be student teaching:
Semester
Will you have children in school?
Yes
Year
No
If so, what school(s) will your children attend?
School Experience:
List name of school, city, and state. If you attended more than one High School, please list all attended.
Elementary School:
Middle School:
High School:
Number of students in graduating class:
High School Awards and/or Extra Curricular Activities (no longer than 3-4 lines):
College Experiences:
Other Colleges Attended:
College Honors, Awards and/or Extra Curricular Activities (no longer than 3-4 lines):
Experiences with young people:
Include: Experience, Age Group, Location, Dates From/To (no longer than 3-4 lines):
Academic Advisor: Bianca Villarruel
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Please check all the courses in your major that will be completed prior to student teaching. Include others
that may be of interest to your supervising teacher.
General Chemistry I/ CHM 115
General Chemistry II/ CHM 116
Organic Chemistry & Lab 1/ CHM 261/263
Organic Chemistry & Lab 2/ CHM 262/264
(Heat) Electricity & Optics/ PHYS 251 or 261
Analytical Chemistry/ CHM 321
Biochemistry/ CHM 333
Physical Chemistry/ CHM 372
Science Elective : __________________________
Science Elective : __________________________
Science Elective : __________________________
Chemistry Elective : ________________________
Strategies for Science Instruction/ EDCI 346
Other Courses:
Course Related Experience:
List any course work where you were required to observe or work with learners in a middle or high school setting. State what you
did to assist the teacher and/or students, the date of your experience, the name of the school, and the name of the course:
CRIMINAL HISTORY
Are you currently under investigation or is disciplinary action pending against any licensure in any state or territory of the US?
Yes
No
Have you ever been convicted, entered a plea of guilty, nolo contender (no contest), or have you ever been sentenced, served time
in jail or prison, or had probation or sentence deferred in any felony or undesignated offense?
Yes
No
SIGNATURE
I understand that by signing this form, 1) I certify that the information provided on this application is accurate and true; 2) I agree to
abide by the PNC Education Department’s policies, rules, and regulations regarding student teaching; 3) I am responsible for
notifying the PNC Education Department if I am charged with a felony, misdemeanor, or infraction at any time while enrolled in the
PNC Education program; 4) I am responsible for providing the PNC Education Department with proof that I meet all student
teaching application requirements one month prior to student teaching; 5) I will provide transcripts
if requested by a school corporation for a student teaching placement; and 6) I am aware that any falsified information may result in
denial of student teaching and dismissal from the Education program at Purdue University North Central.
By signing this complete application, I affirm that I am the individual to whom this information pertains.
I further agree that, for the purposes of authorizing and authenticating an electronic application, my electronic signature has the full
force and effect of a signature affixed by hand to a paper document.
Printed signature
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Date
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Philosophy of Teaching
Describe 3-5 qualities that you possess that will enable you to be an effective educator.
grammar and double space between paragraphs. (Please use no more than one page)
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Be positive!! Note: Check spelling and
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