INSTRUCTIONS FOR COMPLETING INTERNSHIP APPLICATION
SECONDARY EDUCATION
Applications are due in the office of the Director Teacher Education Student Services on
October 1st for Spring Semester and March 1st for Fall Semester
Please read and follow ALL of these instructions carefully!
1.
Set up an appointment with your Content Area Advisor (English, math, history, etc.)
2.
Go to One Tech, sign in, click on student tab, follow the menu, PRINT a copy of your ATU Transcript. Do not go to
the registrar’s office and do not go to your advisor for a copy of your ATU transcript. If you have transfer work,
you will need an unofficial copy of ALL TRANSFER WORK. You will also need an APPROVED COPY of your degree
audit and any waivers you may have. You should be able to get all copies from your content advisor. Also required is a
copy of your admission ticket for Praxis II (not needed if passing Praxis II scores are on file)
3.
Take the following forms with you for your appointment with your Content Area Advisor:
a.
Proposed Study Plan
b.
Internship Application
c.
Major GPA Worksheet
d.
Copies of ALL your unofficial transcripts, substitution forms, waivers and degree audit will be needed. Your
Content Area Advisor and your Education Advisor will need these forms. Do Not Leave Them With Your
Content Area Advisor.
4.
Complete the first section of the application marked “To be completed by the applicant”
5.
Complete the “Proposed Study Plan Form” and the “Major GPA Worksheet” with your Content Area Advisor. Do not
forget to get his/her signature on the “Proposed Study Plan.”
6.
Make an appointment with your Education Advisor in the College of Education; please let him/her know that this
appointment is for filing out your Internship Application.
7.
Complete the Field Experience Review Form (both sides).
8.
Complete the Personal Data Summary. (This form is on the “T” Data Drive in the June Lawson folder – keep the
form to one page) This form will be sent to the school where you will be assigned for internship. Careful attention
should be given to the completion of this form. Academic training should include all colleges and high schools
attended.
9.
Take all of the completed forms mentioned above with you to your appointment.
10.
When you arrive for your appointment with your Education Advisor, please indicate to the secretary that you are here
for your internship advising appointment. Make sure you have with you your complete Internship Application, Proposed
Study Plan (with proper signatures), and copies of all unofficial transcripts, substitution forms, waivers and degree
audits.
*ADDITIONAL INFORMATION*
The College of Education must have received from PRAXIS a DESIGNATED INSTUITION SCORE REPORT with
passing Praxis II Content Knowledge Score(s) (HPE, LSED, PSED require two Praxis II Tests) prior to the first
day of block. Be sure to have your score(s) report(s) sent to both ATU (code #RA6010), and the State Department of
Education (code #R7031). Failure to do this will result in an additional fee for requesting duplicate scores, and will slow
the processing of your application.
Be sure to enroll in SEED 4809 OR 4909, SEED 4503 Seminar in Secondary Education--and content area methods
4701 if applicable. Your placement for internship may be delayed if you do not pre-register.
The Office of The Director Teacher Education Student Services will notify you, by one tech e-mail of your status
(usually after the end of the current semester) and arrange for your placement. Do not contact schools until your
placement is confirmed by this office.
Issued for the Fall 2015 Semester Only
SECONDARY EDUCATION INTERNSHIP APPLICATION for the Fall 2015 Semester
Top Section To Be Completed by the Applicant
This application must be complete to be considered for admission into Internship.
Name: ________________________________________
(Last)
(First)
Maiden: ________________________________
(Middle)
SS #______________________ T #_________________
Birth Date: ______________________________
Address: ______________________________________
OneTech e-mail address: __________________
City: __________________________________________
Phone #: (
State: _________________________ Zip: ___________
Cell Phone #: (
) __________________________
) _______________________
ALL TRANSFER TRANSCRIPTS, APPROVED SUBSTITUTION FORMS, DEGREE AUDIT OR WAIVERS AND A COPY
OF YOUR ADMISSION TICKET FOR THE PRAXIS II (not needed if a passing score is not currently on file), MUST
BE ATTACHED TO THIS APPLICATION.
Is this application for Licensure only? Yes _____ No _____
Have you ever been convicted of a felony?
Yes_____
No_____
Candidate Signature: _____________________________________________________Date______________________
To Be Completed by Secondary Education Advisor
Grade Point Average: Cumulative (including all transfer work): __________________Major GPA: ____________
(Please complete the attached major GPA worksheet and list courses in the area of specialization considered in the
calculation on the back.)
If the candidate has not completed the PRAXIS II Content Knowledge Test(s), when does the candidate plan to take or
retake the test(s)? ______________________________________________________________________________
List any courses in the field of specialization or professional education with grade(s) of “D” or “F”
_________________________________________________________________________________________________
List any course substitutions affecting the completion of the field of specialization or professional education.
_________________________________________________________________________________________________
Has the candidate received College of Education Academic Clemency? *Yes _____ No ______
*If yes, attach a copy of the academic clemency form.
Has the candidate completed 12 semester hours in residence at ATU? Yes _____ No _____
Recommended By Secondary Education Advisor: _______________________________________Date___________
To Be Completed by Director Teacher Education Student Services
Praxis II Score(s):Spec. Name: _______________________________________________________Score: _______
Has the candidate received approval from the Dean of Students? Yes ______________No ____________
Approved: ________
Date: _____________
Denied: __________
Date: _____________ Reason: ____________________________________________________
PROPOSED STUDY PLAN
INTERNSHIP
To be completed by Candidate and Content Area Advisor
Name: ___________________________________________Teaching Field: ___________________________________
Campus Mailing Address: ___________________________________________________________________________
Permanent Address: _______________________________________________________________________________
YEAR OF CATALOG CANDIDATE IS SCHEDULED TO GRADUATE UNDER: (same year as degree audit) ___________
COURSES NOW IN PROGRESS
Summer, 20________
Fall, 20
Spring, 20 _________
Summer, 20
Signature of candidate: ________________________________________
Date: _____________________
As a representative from the Department of __________________________, I recommend that this candidate be
admitted to the requested stage of the ATU Teacher Education Internship Program.
Content Area Advisor: _________________________________________ Date:
As a representative from the DEPARTMENT OF CURRICULUM & INSTRUCTION, I recommend that this candidate
be admitted to the requested stage of the ATU Teacher Education Internship Program.
Education Advisor: ____________________________________________ Date:
Issued for the Fall 2015 Semester Only
Secondary Education Field of Specialization
Major GPA Work Sheet (taken from the Registrar’s Degree Audit Check List) for Fall/Spring 20 ______
(use reverse side for Music Majors (Music use only courses required for degree) & PE Majors)
To be completed by Candidate and Content Area Advisor
Name: _______________________________________________
COURSE PREFIX
COURSE NUMBER
T # _____________________________
GRADE
HOURS
Sub Total
POINTS
Sub total
DATE: ______________at time of application
MAJOR GPA: _____________
DATE: ______________at time of approval
MAJOR GPA: _____________
Departmental Approval ________________________________________
Continue on side two
Continued from side one-----Student’s Name: _______________________________________________
COURSE PREFIX
COURSE NUMBER
Sub totals
TOTALS
Issued for the Fall 2015 Semester Only
GRADE
HOURS
POINTS
Arkansas Tech University
Teacher Education Program
Field Experience Review for Secondary Internship Placement Form
(The information provided will be used to make appropriate pre-service placements in the field. Placements are the
administrative decision of the College of Education through the Director of Teacher Education Student Services and are
final.)
Name: _______________________T # ____________ OneTech e-mail address __________________Date__________
Current Address: ____________________________________________________Phone # (
) __________________
What is your major field? Check one of the following:
Agriculture
Art K-12
Business
Creative Writing
English
Foreign Language
French
German
Spanish
Health and PE K-12
Mathematics
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
Music Instrumental
Music Vocal K-12
Life Science and Earth Science
Physical Science and Earth Science
Chemistry Option
Geology Option
General Option
Physics Option
Social Studies
Speech
______
______
______
______
______
______
______
______
______
Are you currently employed by a public school? Yes _____ No _____If yes, complete the following:
___________________________
_____________________________________________________________
(Position)
(Name of School District/City)
Do you have relatives currently employed by a public school? Yes _____ No _____If yes, complete the following:
___________________________
_____________________________________________________________
(Position)
(Name of School District/City)
Do you have children attending public school? Yes _____ No _____If yes, complete the following:
________________________________________________________________________________________________________
(Name of School/ District/City)
Year you graduated from High School: _______
Name of High School: ____________________________________________
Demonstrate the diversity and variety of experience you have accumulated in the field during your preparation in teacher education.
Complete the following table: (might include observing in classrooms, tutoring, reading to a child, working in camps or with youth
groups, teaching lessons, etc.)
COURSE
SEED 2002
SEED 4052
SEED 4556
Any Other
NAME OF SCHOOL/CITY
# HOURS
GRADE LEVELS(S) TYPE OF EXPERIENCE
Describe any related work experience you have completed in the last 4 years:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
List any minors and the courses you will have completed for areas of endorsement:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Describe any limitations/disabilities/special considerations that may affect an appropriate placement:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Please list three school districts for consideration as the Director Teacher Education seeks your appropriate placement.
You may not include the school at which you completed SEED 2002 or the school(s) at which you have children
attending or relatives employed. Choose from the following approved school districts. Atkins, Clarksville, Coal
Hill (Westside), Danville, Dardanelle, Dover, Hartman, (Westside), Hector, Lamar, Ola, (Two Rivers), Ozark, Paris,
Plainview (Two Rivers), Pottsville, Russellville, Scranton, South Conway County (Morrilton). YOUR CHOICES
ARE A STATEMENT OF PREFERENCE ONLY.
Comments:
For Office Use Only
School ___________________________________________________
Supervising Teacher ________________________________________
Grade/Subject _____________________________________________
Issued for the Fall 2015 Semester Only
INTERNSHIP PERSONAL DATA SUMMARY
(Must be typed or keyed on computer and must be one page only)
Name: _________________________________Major: _______________Minor:__________________
Expected Date of Graduation: _______________Date of Birth: _________
Current Address: ____________________________________________ Current Phone: ____________
____________________________________________
____________________________________________
Permanent Address: __________________________________________ Permanent Phone: _________
__________________________________________
__________________________________________
__________________________________________
Do you have any disability or physical limitations? _____ if so, please specify:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Academic Training
Name of School:
Location:
Dates Attended:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Extra-Curricular Activities Participated in during High School:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Extra-Curricular Activities Participated in during College:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Can Help Direct (Music, Art, Band, Choir, etc.):
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Personal Distinctions and Abilities:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Revised 9/1/14