Office of Career Services

OFFICE OF CAREER SERVICES

McPHERSON COLLEGE

1600 E EUCLID

PO BOX 1402

McPHERSON, KS 67460

RELEASE FORM

Name_____________________________________ Date ____________________

I hereby authorize the office of Career Services at McPherson College to release my credentials file containing references and personal information only under the conditions I have indicated:

1) I desire to have my credentials file released only upon specific written request from me.

Signature _______________________________ Date ___________________

2) I desire to have this form become a continuing release of my credentials file for any further requests by me whether by letter, phone, or in person.

Signature ________________________________ Date ____________________

3) I desire to have my credentials file released to potential employers. This may be done at my request, at the potential employer’s request, or by the office of Career Services.

Signature ________________________________ Date ____________________

I understand that if more than one option is indicated, the office of Career Services will follow the most restrictive option indicated. (I am aware that it is my right to change and update this release form.) I understand that my transcript is not a part of my credentials file. Transcripts may be obtained by written request from Student Enrollment Services.

I understand my rights under “The Family Educational Rights and Privacy Act of 1974, Public Law 93-380, Section 438, Buckley Amendment.” I have the right to either an open file in which I reserve the privilege to have access to all materials within my credentials file, or I can have a closed credentials file where I waive my privilege to see the personal references located with the file. I am aware that it is the policy of the office of Career Services that no file may be changed from open to closed, or closed to open after it has been established. If I wish to make such a change an entirely new file must be started. In compliance with Public Law 93-380, Section 438, Buckley Amendment, I hereby choose to:

_____ (a) waive my privilege to see any and all personal references collected at my request. If in the future I choose to have an open file, references written in confidence may be rewritten at the request of the writer.

_____ (b) hold an open file. I wish to have the opportunity to see any and all references collected.

Signature ____________________________________ Date ___________________

OFFICE OF CAREER SERVICES

McPHERSON COLLEGE

1600 E EUCLID

PO BOX 1402

McPHERSON, KS 67460

LIST OF REFERENTS

I. I verify that I have either personally or in writing asked the following persons to write a reference for my credentials file. I understand that the Career Services Office will send the reference form directly to the persons listed.

Signature ____________________________________ Date ____________________

II. Please give complete names and addresses of the persons you have chosen and asked to serve as referents.

A. College Instructors (one should be your student teaching supervisor)

1. _________________________ 3. _________________________

___________________ ___________________

2. _________________________ 4. _________________________

___________________ ___________________

B. Business or Community Contacts

1. _________________________ 2. _________________________

___________________ ___________________

C. Cooperating Teacher(s)

1. _________________________ 2. _________________________

___________________ ___________________

OFFICE OF CAREER SERVICES

McPHERSON COLLEGE

1600 E EUCLID

PO BOX 1402

McPHERSON, KS 67460

PERSONAL DATA

Name ________________________________________________________________________

Present Address _____________________________ Present Phone __________________

______________________

Permanent Address ____________________________ Permanent Phone _______________

_____________________

EDUCATIONAL BACKGROUND

High Schools and Colleges Attended Length of Attendance Year of Graduation Degree Earned

Include Name, City, and State

_________________________ _______________ _____________ ___________

TEACHING CERTIFICATION

Teaching Field(s) Endorsement Number(s)

_____________________________________ ________________________

Provisional Endorsement Field(s) (One Year) Endorsement Number(s)

_____________________________________ ________________________

TEACHING EXPERIENCE & OTHER SIGNIFICANT WORK

Employer Inclusive Dates Type of Work

________________________ ________________________ __________________

STUDENT TEACHING EXPERIENCE

School and City Inclusive Dates Grade/Level Cooperating Teacher

___________________ ______________ _____________ __________________

COLLEGE HONORS AND ORGANIZATIONS

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ACTIVITY PARTICIPATION (Indicated by years of participation)

High School College Community

Band ___________ ___________ ___________

Orchestra ___________ ___________ ___________

Chorus ___________ ___________ ___________

Debate ___________ ___________ ___________

Dramatics ___________ ___________ ___________

Journalism ___________ ___________ ___________

Football ___________ ___________ ___________

Basketball ___________ ___________ ___________

Softball ___________ ___________ ___________

Volleyball ___________ ___________ ___________

Track ___________ ___________ ___________

Other ___________ ___________ ___________

Educational Philosophy

Signature ____________________________________ Date ___________________