Student Teaching / Internship Application
Fall 2014
Teaching Major __Spanish Teaching__ Teaching Minor _TESOL Bilingual K-12__
__Nielson________, _Lindsey
Last Name
____ _Marie_______________ (__Sowards________)
First Name
Middle Name
Maiden Name
_509246526________ _babscountry@gmail.com__ __719 588 6554__
BYU Student ID #
Current email address
Local Phone # _55 W 1450 N #159 Provo, UT
84604_______________________________________________________
Local Street Address (BYU)
City
State
Zip Code
1. Mark the assignment you are requesting. (Choose only one assignment)
Internship (full year)
Student Teaching (one semester),
National / International Student Teaching (one semester)
Houston, TX
Washington DC
Yes
No 2. Are you an International Student? (If “Yes”, do you have a green card? Yes No)
Yes
No 3. Are you a Post-Bacc student?
Yes
No 4. Do you own a vehicle or have access to a vehicle? (You will be responsible for transportation to your assigned school.)
5.
Which TESOL practicum are you completing during your Student Teaching or Internship?
(TESOL K-12 & Dual Language Immersion minors)
TELL 477R
TELL 478R
Not completing a TESOL practicum Fall semester
6.
Foreign language proficiency (if any):__________________________________________________________________
7.
Marital status at time of student teaching: Single
8.
El Ed / ECE Grade Level Preference (K-6 grades - El Ed; K-3 grades – ECE; does not guarantee placement) _____1st Choice
_____2nd Choice
9.
District Preference (ScEd & SpEd; Student Teaching only) (Rank preference 1-5; 1 being your first choice)
_2__Alpine
__4___Jordan
__3___Nebo
__1___Provo
_5__Wasatch
Married
10. Indicate Grade Level Preference (ScEd & SpEd only) (Rank preference 1-3; 1 being your first choice)
__3___ Elementary
__2___Middle / Jr. High
__1___High School
11. Please describe below any special requests or circumstances that may affect your assignment:
ElEd Majors complete your Practicum information below
Practicum Semester
Term/Year
Liaison
Kindergarten – 2nd
3rd – 6th
Emergency Information:
Who should be contacted in case of emergency?
District
School
Grade
Name: __Moydie Nielson____ Relationship: __Spouse____
Address: __55 W 1450 N #159 Provo, UT 84604__ Phone #: __435 749 0087__
Applicant Responsibility
I verify that all my general education and major/minor program requirements will be completed before I begin my student teaching or
internship. Otherwise, I have attached a course deficiency appeal form identifying my incomplete course(s).
___________________________________________________________________
Applicant’s Signature
____________________
Date
.
FOR OFFICE USE ONLY
Info Page
EECROI
Sc Ed Signature
Autobiography
ST License
Ed License Info
Praxis
Initials _____
Revised 11/2013
-1-
Name: Lindsey Nielson
Email: babscountry@gmail.com
BYU ID: 509246526
NET ID: limaso
_________________________________________________________________________________
Electronic Release of Information
In accordance with the Family Educational Rights and Privacy Act (FERPA), Education Student Services
(ESS) is committed to protecting the privacy of your educational records. We need your express written
permission for ESS to release personally identifiable or educational information to you through electronic
means.
If you would like us to be able to communicate with you regarding your personally identifiable educational
information through e-mail, please sign the agreement below and return this document to the ESS office.
Be assured that we do not share emails or other contact information with any other entity except BYU
and the Utah State Office of Education (USOE).
_________________________________________________________________________________
I hereby give Education Student Services permission to communicate with me regarding my educational
records, credit hours, grades, academic standing, etc., through the email address listed on my MyBYU
account. I further give permission for ESS to correspond with USOE regarding my licensing
requirements.
__________________________________
Signature
__________________
Date
Secondary Education Signature Page
(Only Seconday Ed Majors need to submit)
Student Name:__Lindsey Nielson__ BYU ID#:_509246526__ Teaching Major:__Spanish____
1. You are required to meet with an advisor in your major advisement center before we can process your Student Teaching
Application. Once you have met with an advisor, have them sign this form on the line below verifying that you have
completed all program requirements except for student teaching. If you are not sure who your advisor is, please see
the table below.
I
have met with this student and verify completion of all program requirements except for student teaching. Any
deficiencies are listed below the signature line.
Major Advisor: ___________________________________________________
Date:________________________________
Deficiencies:__________________________________________________________________________________
_______________
Major Subjects
Art Education/Theatre Education
Biology Science Education
Chemistry/Earth & Space/Math/Physics
Teaching
Dance Education/Music Education
English Teaching
Family & Consumer Science Education
French/German/Spanish/Latin Teaching
History Teaching/Teaching Social
Science
Physical Education
School Health Education
Technology & Engineering Education
Major Advisement Center
Advisor
Location
Fine Arts & Communication
Life Sciences
Physical & Mathematical
Sciences
Fine Arts & Communication
Humanities
Family Home & Soc Sci
Humanities
Family Home & Soc Sci
Julee Braithwaite
Lisa Buzan
Shane Jorgenson
D-444 HFAC
380 WIDB
N-181 ESC
Megan Beardall
Paula Landon
Kristi Madsen
Landon/Schofield
Kirk Kirkham
D-444 HFAC
1175 JFSB
1041 JFSB
1175 JFSB
1041 JFSB
Education Student Services
Life Sciences
Engineering & Technology
Brandan Beerli
Lisa Buzan
Beverly Harmon
350 MCKB
380 WIDB
230 SNLB
2. You are required to have met with your assigned Student Teacher Supervisor before your student teaching application
is complete. If you are not sure who your Student Teacher Supervisor is, please check the table below. Once you have
met with your assigned Student Teacher Supervisor, have them sign this form on the line below.
I
have met with the student to get acquainted and discuss their specific student teacher placement needs.
Student Teacher Supervisor:____________________________________________
Date:_____________________________
Major Subject
Student Teacher
Office
Phone
Supervisor
Location
Email
Art Education
Mark Graham
3122 JKB
Biology Sci Educ
Marta Adair
A115K CLFB
Dance Education
Kori Wakamatsu
289 RB
English Teaching
Chris Crowe
Dixie Archibald
4121 JFSB
4168 JFSB
Fam & Cons
Science
French Teaching
Chris Moore
2073 JFSB
Robert Erickson
3105 JFSB
German Teaching
Teresa Bell
3103 JFSB
History/Soc Sci
Jeff Nokes
Cindy Horrocks
2160 JFSB
219 MCKB
Latin Teaching
Roger Macfarlane
3048 JFSB
Math Education
Bob Wadley
Amy Tanner
185 TMCB
187 TMCB
Music Education
Megan Beardall
D-444 HFAC
Phys
Sci/Chem/Physics
Physical Education
Duane Merrell
N-143 ESC
Todd Pennington
249C SFH
School Health Educ
Cougar Hall
229E RB
Spanish Teaching
Cherice Montgomery
Andrea Nielsen
3177 JFSB
Tech & Engineering
Ron Terry
Beverly Harmon
265-K CTB
230 SNLB
Theatre Education
Amy P Jensen
Julia Ashworth
D-581 HFAC
D-581 HFAC
801-4225688
801-4228336
801-4225148
801-4223429
801-4223398
801-4227171
801-4225193
801-4224961
801-4227520
mark_graham@byu.edu
801-4222864
801-4223734
801-4223640
801-4223777
801-4222255
801-4222335
801-4225656
801-4223465
208-2408422
801-4224297
801-4221818
801-4221886
801-4224539
roger_macfarlane@byu.edu
marta_adair@byu.edu
kori_wakamatsu@byu.edu
chris_crowe@byu.edu
dixie_archibald@byu.edu
christine_moore@byu.edu
rob_erickson@byu.edu
teresa_bell@byu.edu
jeff_nokes@byu.edu
cindy_horrocks@byu.edu
wadley@mathed.byu.edu
ajeppsen@mathed.byu.edu
megan_beardall@byu.edu
duane_merrell@byu.edu
todd_pennington@byu.edu
cougar_hall@byu.edu
cherice_montgomery@byu.edu
andrea_nielsen@byu.edu
ron_terry@byu.edu
beverly@harmon@byu.edu
amy_p_jensen@byu.edu
Julia_ashworth@byu.edu
3. Please include this form (with required signatures) with your student teaching application on or before the
application deadline to 350 MCKB. Hours are Monday-Friday, 8am-5pm, except for devotionals and Holidays.
Questions, please call 801-422-3426.
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Revised 11/2013
AUTOBIOGRAPHY
Teaching Major _Spanish___ Teaching Minor __TESOL Bilingual K-12____
____Nielson___, _Lindsey_______ _Marie______ (__Sowards_____)
Last Name
First Name
Middle Name
Maiden Name
_509246526___ _babscountry@gmail.com__ _719 588 6554________
BYU Student ID #
Current email address
Local Phone #
_55 W 1450 N #159 Provo, UT 84604_ __________ _________ ________
Local Street Address (BYU)
City
Autobiography
In the space below please type an autobiography which may include
family/background, education, work, travel, interests, and talents highlighting skills
that could be utilized in your teaching, and your reasons for choosing the teaching
profession.
( Keep in mind that you are writing to a potential, future employer.
You want to remain professional & concise.)
State
Zip Code
PHOTOGRAPH
Insert a professional looking
head & shoulders color
photo of yourself ONLY!
(Photo must fit in this box.)
(Please trim extraneous background on attached photos.)
(You may color copy the original)
I grew up in Alamosa, Colorado which is forty minutes north of the New Mexican border. The
community consisted of Mexicans, Guatemalans, Americans, and African-Americans. My high school was half
Hispanic.
I graduated from Alamosa High School and I am completing my Spanish Teaching education at Brigham
Young University.
I have worked as a tutor for bilinguals many times during high school and my university studies. I am
interested in different cultures, languages, and countries. I like exploring athletics and health and I love reading
novels in Spanish.
I am a very amiable person with many personable attributes. I can identify with students of high school
age and I always get what I want.
I chose to become a Spanish teacher after taking Spanish for six years and I realized that my dream job
would be to teach the Spanish language and culture to high school students that need a little enlightenment with
an intriguing and fun perspective.
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REPLACE THIS PAGE WITH
Revised 11/2013
STUDENT TEACHING LICENSE. (Not
required for NISTP)
*Obtaining Temporary Student Teacher/Intern License
Go to: www.utah.gov/teachers
-
Select the Student License menu item,
-
fill in the required information,
-
pay the fee, and - print the license.
*You must be registered with the Utah State Office of Education (USOE) and have cleared fingerprints. If you do not have cleared fingerprints, you can
complete this at the following link (contact ESS for any questions): http://education.byu.edu/ess/fingerprint.html
PLACEHOLDER ONLY – DO NOT INCLUDE WITH APPLICATION
Revised 9/2012
EDUCATOR LICENSE INFORMATION
Teaching Major __Spanish__________________ Teaching Minor __TESOL Bilingual K-12___________
__Nielson_____, _Lindsey_________ _Marie_____ (_Sowards_______)
Last Name
First Name
Middle Name
Maiden Name
_509246526____ _babscountry@gmail.com______ _719 588 6554___
BYU Student ID #
Current email address
Local Phone #
_55 W 1450 N #159 Provo, UT 84604____________ _________ ________
Local Street Address (BYU)
City
State
Zip Code
I certify that I will complete the following requirements:
1. I will obtain prior approval from Education Student Services (ESS) in 120 MCKB before making changes
in my major or minor program.
2. I will contact my University Supervisor and ESS if extenuating circumstances require the cancellation of
my student teaching or internship experience.
3. I agree to pay additional cost (including tuition) in the event that I need an extended experience or need
to repeat or reschedule my student teaching or internship experience.
4. I have or will submit an online graduation application before beginning my student teaching program.
Begin your online graduation here: http://saas.byu.edu/registrar/graduation/apply.php
Teaching major/minor minimum grade & GPA policy
Grades below C- in professional education courses or content courses will not be accepted in the teaching major
or teaching minor. Teacher candidates must have a cumulative 2.85 GPA in teaching major and teaching minor
courses to qualify for student teaching.
Student Teaching / Internship Evaluations
I understand that upon completion of my student teaching/internship program, ESS will provide me with a copy of
my student teaching / internship evaluations.
I understand that my student teaching / internship evaluations will be sent to me electronically as a digital .pdf
file, to my email address listed on Route Y.
Note: You are responsible to retain and preserve your student teaching/internship evaluations. After one year
following your graduation, your student teaching / internship evaluations will no longer be available for general
distribution. In the first year following graduation, additional copies of your student teaching / internship
evaluations may be obtained from the ESS upon payment of a fee of $5.00 per evaluation. We urge you to take
appropriate measures to preserve these records for safekeeping.
State Licensing
I authorize ESS to send any documentation requested by the Utah State Office of Education for licensing. After
graduating and as soon as reasonably possible, the ESS will notify me by email using my email address listed on
Route Y, that my file has been submitted for licensing and that I may go online to complete the licensing process.
I will keep my Route Y mailing address and email current.
My signature confirms my understanding of and agreement to comply with the conditions stated above.
Student Signature _______________________________________________
Date _______________
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Revised 11/2013
COURSE DEFICIENCY APPEAL FORM
Teaching Major __Spanish_____________________ Teaching Minor _TESOL Bilingual K-12___________
__Nielson_______, _Lindsey______ _Marie_____ (_Sowards_______)
Last Name
First Name
Middle Name
Maiden Name
_509246526_____ _babscountry@gmail.com___ _719 588 6554________
BYU Student ID #
Current email address
Local Phone #
_55 W 1450 N #159 Provo, UT 84604______________ _________ ________
Local Street Address (BYU)
City
State
Zip Code
_____ I request permission to take the following course concurrent with student teaching.
(Course Name/Catalog #/Credit Hrs)
(Semester & Year; Independent Study)
_________________________________________
_______________________________
_________________________________________
_______________________________
_____ I request permission to take the following course subsequent to student teaching.
(Course Name/Catalog #/Credit Hrs)
(Semester & Year; Independent Study)
_________________________________________
_______________________________
_________________________________________
_______________________________
_________________________________________
_______________________________
Please explain why you are appealing to take the above course(s) concurrent or subsequent to your
student teaching / internship:
_____________________________________________________ _______________________
Signature of Applicant
Date
I have reviewed the above appeal and confirm that the courses listed above will complete all requirements for graduation.
This appeal is recommended based on the following extenuating circumstances:
______________________________________________________
Education Student Services Advisor’s Signature (120 MCKB)
________________
Date
El Ed / ECE / Sp Ed Only
I approve the above appeal for courses taken concurrently with student teaching and/or major course
deficiency.
_____________________________________________________
El Ed/ECE Liaison – Sp Ed Supervisor Signature
_____________________
Date
-7-
Revised 8/2012
PRAXIS II EXAM SCORE
Teaching Major __Spanish___________________ Teaching Minor _TESOL Bilingual K-12___________
__Nielson______, _Lindsey_______ _Marie______ (_Sowards______)
Last Name
First Name
Middle Name
Maiden Name
_509246526____ _babscountry@gmail.com___ _719 588 6554_______
BYU Student ID #
Current email address
Local Phone #
_55 W 1450 N #159 Provo, UT 84604______________ _________ ________
Local Street Address (BYU)
City
State
Zip Code
This form will provide ESS with necessary information regarding your requirement to complete the designated Praxis II
Test(s) for all licensure & endorsement areas associated with your teaching major & minor(s). Please submit it with your
Student Teaching Application.
Complete the section that best describes your particular circumstance.
If you have:
-
taken & passed the USOE required Praxis II Test for all licensure & endorsement areas. o Provide ESS with the
necessary information below.
Section 1 o
Submit a hard copy of the most up-to-date official Praxis Score Report with your student teaching
application. The Score Report must include all required test scores, codes, & date taken.
Date Test Taken
Test #1
Test #2
Test #3
Test #4
Praxis Test Code
Score
-
registered, through Educational Testing Service (ETS), to take all necessary Praxis II Test(s) in the near future.
o Provide ESS with the necessary information below.
Section 2 o
Submit a hard copy of your registration verification email from ETS. The email should indicate scheduled test
date & test code for each test registered for.
Date Registered
Praxis Test Code
Test #1
Test #2
Test #3
Test #4
Section 3
not yet registered for the required Praxis II Test(s) at the time of student teaching application submission. o In
the comment box below, provide ESS with a statement explaining your reason for delay in registration
for the Praxis test(s), and your plan for completing it.
Reason for Delay
Completion Plan
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Revised 11/2013
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REPLACE THIS PAGE WITH YOUR
byu.experience.com HOMEPAGE.
INSTRUCTION ONLY – DO NOT INCLUDE WITH APPLICATION
Space Holder
Revised 6/2011
REPLACE THIS PAGE WITH A COPY OF
YOUR OPI RESULTS. (Language Majors
& Minors Only)
Including Dual Language Immersion
INSTRUCTION ONLY – DO NOT INCLUDE WITH APPLICATION
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Revised 10/2012
Intern Candidate Responsibility Form
All internship candidates are required to sign a responsibility form prior to being
accepted for an internship. If you are intending to apply for an internship, please
select the link below for your teaching major area. You will print the form from
the link, and then sign & submit the form as the last page of your internship
application.
Secondary Education
http://education.byu.edu/sites/default/shared/documents/ess/documents/Intern%20Candidate%20Respo
nsibility-SCED%202014-2015.pdf Special Education
http://education.byu.edu/sites/default/shared/documents/ess/documents/Intern%20Candidate%20Respo
nsibility-SPED%202014-2015.pdf
Elementary Education
Elementary Education majors do not need to attach the Intern Candidate Responsibility Form to the
Student Teaching Application. This form will be provided at the District Interview Sign-up meeting in
March. Candidates will sign & submit this form at that time.
PLACEHOLDER ONLY – DO NOT INCLUDE WITH APPLICATION
Revised 12/2013