USI Student Teaching Application for Term:

Directions to the candidate: To complete this application, you will need a copy of the Directions, your DARS report, and a program sheet from your major. After the application has been approved by your advisor, you should print one copy of pages “A” and “B.” These pages will be kept in the Teacher Education office for our records. You must print three copies of pages 1 and 2 of the application and your essay responses. These pages are circulated to school officials for placement purposes.

Candidate Information
Name: / Student ID #
Date of Admission to Teacher Education: / Term/Year You Plan to Student Teach:
Date of Birth: / USI Email:
Major(s): / Minor(s):
Local Address:
Local Phone: / Permanent Phone:
Permanent Address:
USI Hours Completed: / USI GPA: / Transfer Hours Completed:
List the schools from which you graduated.
School Name, City, State / Year
Elementary or K-8
Middle School/Jr. High
High School
Community College or University
List your preferences of IN and IL school corporations/districts within a 50 mile radius of campus for your student teaching assignment. If you prefer the Evansville Diocese schools, list the cities.
Corporation or District / City or County
Do you have any relatives who attend or are employed by any K-12 school locally or in the corporations you listed above? If so, list those schools.
Have you ever been a student in a teacher education program, other than at USI?
YES NO
Areas of Licensure
P - 3
K - 6
5 - 12 List subject area(s):
P – 12 List subject area(s):
List the following information about your three most involved field experiences:
Duties in Field Experience:
Teacher: / School:
Grade: / Term/Year:
Duties in Field Experience:
Teacher: / School:
Grade: / Term/Year:
Duties in Field Experience:
Teacher: / School:
Grade: / Term/Year:
Remaining Coursework
In the chart below, list the courses that you have left to complete before student teaching. Organize them by the semester you intend to take them. Type the correct year in the box next to term name. Include course abbreviation, number, and 1-2 word, abbreviated title, as in BIOL 105: Intro Biol. Do not include the synthesis course or student teaching courses.
SPRING / SUMMER / FALL
Courses with brief titles / Courses with brief titles / Courses with brief titles

Note to Advisors: Pages A and B are internal documents which are kept in the office of student teaching. The remaining pages are external documents which are sent to local schools for placement. Your signature indicates that this candidate meets the department requirements and standards, including admission to teacher education, a 2.75 GPA in all licensure areas (all teaching majors and teaching minors), and a 2.75 GPA overall. It also indicates that these papers are ready for external review. Please list the candidate’s GPA in all licensure areas:

Major(s): ______Major(s) GPA: ______

Minor(s): ______Minor(s) GPA: ______

Advisor’s Signature / Date

B

University of Southern Indiana

Department of Teacher Education 8600 University Boulevard Evansville, Indiana 47712 Phone 812.465.7024

Student Teaching Application for Term:

Name: / USI Email:
Major(s): / Minor(s):
Permanent Address: / Phone:
List the Schools From Which You Graduated (School Name, City, State) / Year
Elementary or K-8
Middle School or Jr. High
High School
College or University
Check Areas of Licensure
P - 3
K - 6
5 - 12 / List subject area(s):
P - 12 / List subject area(s):
Reflective Essay Questions: Respond to each of the following questions/writing prompts in essay form on a separate sheet of paper. The length of your answers should be sufficient to address the questions while giving the reader a clear understanding of your preparation and expectations for student teaching. Type each prompt in bold font followed by your response in plain font. The essays should be single-spaced, and all four responses must fit on one piece of paper. Remember to proofread your answers carefully.
1. Describe your educational background and your preparation as a teacher candidate.
2. What special interests, skills, or experiences (e.g. sports, drama, volunteer work, employment, travel, etc.) do you bring to the school or the classroom?
3. What factors influenced you to pursue a career in teaching?
4. What do you consider the three most important attributes of an effective teacher?
Academic Preparation
Every course required for your degree must be listed on this page. For any course that is not complete, including the current semester, list the semester of enrollment. Indicate the subject, course number, brief title, and the grade you earned or semester you plan to enroll in the course.
Courses from the University Core Curriculum / Courses from the Major / Minor
Course Subject, Number, Brief Title
Example: ENG 101: Composition I / Grade Earned or Term of Enrollment / Course Subject, Number, Brief Title / Grade Earned or Term of Enrollment
A1. Composition/Speech (9 hours)
A2. Mathematics (3-4 hours)
B1. Ethics (3 hours)
B2. The Arts (3 hours)
B3. Health/Fitness (2-6 hours)
C1. History (3 hours)
C2. Individual/Social Development (3 hours)
C3. Science (8-9 hours)
C4. Western Culture (6 hours)
C5. Global Communities (3 hours)
Courses in other areas if applicable
This candidate has been recommended for student teaching by his or her academic advisor. The candidate meets all requirements for student teaching.
Mrs. Joyce Rietman, Director of Advanced Clinical Experience and Co-Teaching

2

Academic Preparation
for Students Who Have Earned an Associate Degree or Other Degree Which Meets USI Core Curriculum Requirements
If you hold a college degree, please complete this page to show general education credits and coursework in your major. You may also attach a copy of your transcript from the institution where you earned the degree. If this chart does not accommodate your coursework, please develop a similar chart to convey this information to prospective cooperating teachers, principals, and other school personnel.
Name of the Institution:
Degree Earned:
Date Degree Awarded: / GPA for Degree:
Course Subject, Number, Brief Title
Example: ENG 101: Composition I / Grade Earned or Term of Enrollment / Course Subject, Number, Brief Title / Grade Earned or Term of Enrollment
Courses in English/Speech/Communications / Courses in Education and Content Major
Courses in Mathematics
Courses in History and Social Sciences
Courses in The Arts, Literature, Humanities, World Languages
Courses in Health and Physical Education
Courses in Science
Courses in Other Areas if Applicable
This candidate has been recommended for student teaching by his or her academic advisor. The candidate meets all requirements for student teaching.
Mrs. Joyce Rietman, Director of Advanced Clinical Experience and Co-Teaching

2