Form: JSU Undergraduate Application for Internship (Current)

Owner: JSU Administration <jsuadmin>
Owner's Email: dherring@jsu.edu
Dataset: Current
EDIT: Y, VIEW: N, REQR: N
1
Date:
 (MM/DD/YYYY)
EDIT: Y, VIEW: N, REQR: N
2
First Name:
EDIT: Y, VIEW: N, REQR: N
3
Last Name:
EDIT: Y, VIEW: N, REQR: N
4
Major:
ex: MUI, MUV, CLS, GS, BY, ECE, EED
EDIT: Y, VIEW: N, REQR: N
5
JSU ID#
Format (000000000) NO dashes
Include ALL 9 digits
EDIT: Y, VIEW: N, REQR: N
6
Internship Address:
This is where you will live during Internship.
EDIT: Y, VIEW: N, REQR: N
7
Internship City:
EDIT: Y, VIEW: N, REQR: N
8
Internship State
EDIT: Y, VIEW: N, REQR: N
9
Internship Zip
EDIT: Y, VIEW: N, REQR: N
10
Home Address:
This is where you will receive your placement letter.
EDIT: Y, VIEW: N, REQR: N
11
Home City:
EDIT: Y, VIEW: N, REQR: N
12
Home State:
EDIT: Y, VIEW: N, REQR: N
13
Home Zip:
EDIT: Y, VIEW: N, REQR: N
14
Local Phone:
EDIT: Y, VIEW: N, REQR: N
15
Cell Number:
EDIT: Y, VIEW: N, REQR: N
16
JSU email:
This will be used to communicate with you before and during Internship.
EDIT: Y, VIEW: N, REQR: N
17
Personal email:
This may be used to give you information about job opportunities after graduation.
EDIT: Y, VIEW: N, REQR: N
18
Name all schools in which you have children and/or relatives currently attending/employed:
EDIT: Y, VIEW: N, REQR: N
19
Education History: Please list the system/school name and actual years attended below.
system name, school name, and range of years attended for K-12
EDIT: Y, VIEW: N, REQR: N
20
Practicum I: List the name of the school(s) for your first clinical experience after ED 300.
Placement will be delayed without complete information.
EDIT: Y, VIEW: N, REQR: N
21
Practicum I Grade Level or Special Education Setting
Grade K-3
Grade 4-6
Grade 6-8
Grade 9-12
Mild K-6
Severe K-6
Mild 6-12
Severe 6-12
EDIT: Y, VIEW: N, REQR: N
22
Practicum II: List the name of the school(s) for your second clinical experience.
Placement will be delayed without complete information.
EDIT: Y, VIEW: N, REQR: N
23
Practicum II Grade Level or Special Education Setting
Grade K-3
Grade 4-6
Grade 6-8
Grade 9-12
Mild K-6
Severe K-6
Mild 6-12
Severe 6-12
EDIT: Y, VIEW: N, REQR: N
24
Practicum III: List the name of the school(s) for your third clinical experience.
Placement will be delayed without complete information.
EDIT: Y, VIEW: N, REQR: N
25
Practicum III Grade Level or Special Education Setting
Grade K-3
Grade 4-6
Grade 6-8
Grade 9-12
Mild K-6
Severe K-6
Mild 6-12
Severe 6-12
EDIT: Y, VIEW: N, REQR: N
26
Practicum IV: List the name of the school(s) for your fourth clinical experience.
Placement will be delayed without complete information.
EDIT: Y, VIEW: N, REQR: N
27
Practicum IV Grade Level or Special Education Setting
Grade K-3
Grade 4-6
Grade 6-8
Grade 9-12
Mild K-6
Severe K-6
Mild 6-12
Severe 6-12
EDIT: Y, VIEW: N, REQR: N
28
I certify that I have attended the mandatory pre-orientation to internship meeting/viewed the presentation and have been made aware of internship requirements and procedures. I am submitting complete information to the best of my knowledge on all paperwork. I understand that incomplete applications will not be processed. I further understand that if I submit a completed application beyond the stated application due date, that an internship placement may or may not be possible. I understand that I must have a course analysis completed around the time of application by the appropriate certification advisor in the Teacher Service Center. I am responsible for making this appointment for my evaluation.
Yes
No
EDIT: Y, VIEW: N, REQR: N
29
Have you ever had a teacher's certificate/license revoked, suspended or denied; or have you voluntarily relinquished a certificate/license? (certificate expiration does not apply)
Yes
No
EDIT: Y, VIEW: N, REQR: N
30
Have you ever been arrested for, convicted of, or entered a plea of no contest to a felony or misdiemeanor other than a minor traffic violation? If you answered "yes" please provide details of conviction, including date and place of conviction, or submit court certified copies of the judgement, conviction, and sentencing to the Teacher Service Center. (A "yes" answer will not automatically result in non-placement for internship.)
Yes
No