Form: Coaching TEACHER Info and Payment Form Official

Owner: The Sage Colleges Education <sageadmin>
Owner's Email: SoELTAdmin@sage.edu
Dataset: Coaching Teacher Info and Payment Form Fall 2013
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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 or disseminated; all information is used solely for the purpose of the Esteves School of Education accounting and accreditation
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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
Tax Address Street/ PO Box
Used to mail stipend or certificate
Please phone if any changes of information is needed (518-244-2357).
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6
Home Address City/ Town
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7
Home State
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Home Address Zip Code
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Home phone number
Used ONLY if necessary regarding "Thank You" option.
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10
Email address
List address you use year round. Your email is kept within SoE and not shared with outside businesses.
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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 waiver: The 3 credit course waiver can be used at any of The Sage Colleges WITHIN ONE YEAR of the issue date. It can only be used by you, a colleague or a DEPENDENT CHILD, and not for doctoral-level credits..
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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) 244-2357 to provide the number to the Director of Field/Clinical Experiences.
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Please check this box to indicate this is your electronic signature needed for the $200 stipend.
If checked this is considered my electronic signature.
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14
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.
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15
School District Name
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School Building Name
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School Address Street / PO Box
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School Address City/ Town
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School Address Zip Code
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20
School Phone Number
Include area code
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21
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.
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22
Currently teaching grade(s) _____
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23
What is your current content area?
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Please indicate the number of years you have taught at particular levels. Answer ONLY those areas that pertain to you.
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Primary Grades (K-3)
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Intermediate Grades (4-6)
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Middle School (5th-8th/9th grades)
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Junior High School (7th-8th/9th grades)
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High School (9th-12th grades)
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For the items below, what is your institutional preparation?
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Undergraduate Institution
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Undergrad Major and Degree
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Graduate Institution(s)
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Graduate Degree(s)
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Certifications you have from NYS
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Certifications from other states
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37
Please list all current memberships, positions, and offices in professional associations at the local, state, and national levels.
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38
THANK YOU for being our partner in Education!