SECONDARY – PHYSICAL SCIENCE STUDENT TEACHING APPLICATION
PURDUE UNIVERSITY NORTH CENTRAL
EDUCATION SECTION
1401 S US 421
Westville, IN 46391
(219) 785-5485
Name:
Title, First, Middle Initial, Last
For Office Use Only
Requirements
Staff Initials
Cumulative GPA:
Professional GPA:
Praxis II
Background Check
Signature Form:
Birth Date:
Address:
Street, City, State, Zip Code
Phone:
Date
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
Plane Analytical Geometry & Calculus I/ MA 167
Plane Analytical Geometry & Calculus II/ MA 169
Analyt Chm or Intro to Organ/Biochm/ CHM 321/211
Organist Chemistry & Lab/ CHM 25500/01
Mechanics/ PHYS 152
(Heat) Electricity & Optics/ PHYS 251 or 261
Other Courses:
Environmental Chemistry/ CHM 481
Physical Chemistry/ CHM 372
Modern Physics & Lab/ PHYS 342
Science Elective : __________________________
Science Elective : __________________________
Strategies for Science Instruction/ EDCI 346
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
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.
Electronic 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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