Form: Cooperating TEACHER Info and Payment Form Fall 2012

Owner: The Sage Colleges Education <sageadmin>
Owner's Email: SoELTAdmin@sage.edu
Dataset: Cooperating TEACHER Info and Payment Form Fall 12
EDIT: Y, VIEW: N, REQR: N
1
Thank you for completing this form. We will be asking you every three years to update this information while you remain a cooperating teacher. None of the information is sold; all information is used solely for the purpose of School of Education.
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2
Today's Date
 (MM/DD/YYYY)
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3
Your First Name
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4
Your Last Name
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5
Ethnicity
EDIT: Y, VIEW: N, REQR: N
6
Tax Address Street/ PO Box
Used to mail stipend or certificate
Please let us know if this should change (518-244-2326).
EDIT: Y, VIEW: N, REQR: N
7
Home Address City/ Town
EDIT: Y, VIEW: N, REQR: N
8
Home State
EDIT: Y, VIEW: N, REQR: N
9
Home Address Zip Code
EDIT: Y, VIEW: N, REQR: N
10
Home phone number
Used ONLY if necessary regarding "Thank You" option.
EDIT: Y, VIEW: N, REQR: N
11
Email address
List address you use year round. Your email is kept within SoE and not shared with outside businesses.
EDIT: Y, VIEW: N, REQR: N
12
Your "Thank You" option.
Please check only one item.
$200: If you choose the $200 stipend, your Social Security number or Tax ID number and electronic signature is required below.
m.o.s.s. bookstore $200 gift card
3 credit course voucher: The 3 credit course voucher can be used at any of The Sage Colleges WITHIN ONE YEAR of the issue date. It can be used by you or a colleague.
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13
Social Security number (needed only if you choose the stipend)
Only office staff will have access to this form and your number. If you are uncomfortable listing it, you can call (518) 244-2326 to provide the number to School of Education administrative assistant.
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14
Please check this box to indicate this is your electronic signature needed for the $200 stipend.
If checked this is considered my electronic signature.
EDIT: Y, VIEW: N, REQR: N
15
Name of "other" to receive 3 credit course waiver and this person's RELATIONSHIP TO YOU.
Complete this if you are choosing the course waiver and want to provide it to dependent family member or spouse.
EDIT: Y, VIEW: N, REQR: N
16
School District Name
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17
School Building Name
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18
School Address Street / PO Box
EDIT: Y, VIEW: N, REQR: N
19
School Address City/ Town
EDIT: Y, VIEW: N, REQR: N
20
School Address Zip Code
EDIT: Y, VIEW: N, REQR: N
21
School Phone Number
Include area code
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22
The following information is needed for our accreditation. We must provide data to illustrate our cooperating teachers are qualified through their education and years of teaching.
EDIT: Y, VIEW: N, REQR: N
23
Currently teaching grade(s) _____
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24
What is your current content area?
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25
Please indicate the number of years you have taught at particular levels. Answer ONLY those areas that pertain to you.
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26
Primary Grades (K-3)
EDIT: Y, VIEW: N, REQR: N
27
Intermediate Grades (4-6)
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Middle School (5th-8th/9th grades)
EDIT: Y, VIEW: N, REQR: N
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Junior High School (7th-8th/9th grades)
EDIT: Y, VIEW: N, REQR: N
30
High School (9th-12th grades)
EDIT: Y, VIEW: N, REQR: N
31
For the items below, what is your institutional preparation?
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32
Undergraduate Institution
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33
Undergrad Major and Degree
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34
Graduate Institution(s)
EDIT: Y, VIEW: N, REQR: N
35
Graduate Degree(s)
EDIT: Y, VIEW: N, REQR: N
36
Certifications you have from NYS
EDIT: Y, VIEW: N, REQR: N
37
Certifications from other states
EDIT: Y, VIEW: N, REQR: N
38
Please list all current memberships, positions, and offices in professional associations at the local, state, and national levels.
EDIT: Y, VIEW: N, REQR: N
39
THANK YOU for being our partner in Education!