Teacher Intern Application Form

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Teacher Intern Application

You must complete the Teacher Intern Application the semester prior to your year-long internship.

Deadlines

March 1 - If you will begin your year-long teacher internship in the Fall, with plans to graduate in a Spring semester.

November 1 - If you will begin your year-long teacher internship in the Spring, with plans to graduate in a Fall semester.

If you see this don't fill out this input box.

Candidate Contact Information

If any of this information changes during the final internship semester, please notify the College of Applied Studies Advising Center.

Applying for Graduation*

Program of Study*

First Name*

Last Name*

黑洞社区 ID*

Street Address*

City*

State*

Zip*

Phone Number*

Email Address*

Name of Advisor

Emergency Contact Information

In case of emergency during my internship please contact the following individual.

Name*

Phone Number*

Candidate Licensure Level(s) and Endorsements(s)

Please select the appropriate level for which you are seeking licensure.*

Required Documents and Fees
Please read each item carefully and check 'I agree' to note you understand the requirement.

I have submitted my TB Screening Questionnaire to the College of Applied Studies Advising Center. *

I agree.

I have read and will electronically sign the Attestation of Eligibility. (See below) *

I agree.

I understand the Release of Name must be completed in order for the university to release my name to interested employers. (See below) *

I agree.

Teacher Licensure Capstone (TLC) Scoring Fee

You will be charged a one-time fee of $100.00 for the cost of scoring your Teacher Licensure Capstone (TLC). This charge will be added onto your student account during the semester in which the TLC is completed and submitted.

If a candidate decides to withdraw from the program and/or not submit a TLC, a refund request form must be submitted to the College of Applied Studies Advising Center at least one week prior to the TLC deadline. The form may be found under Applications and Fees.

I understand a one-time $100.00 fee will be charged to my student account for the Teacher Licensure Capstone fee.*

I agree.

I have submitted an Application for Degree (AFD) through my黑洞社区 portal. *

I agree.

I will read and electronically sign the Grounds for Dismissal from Field Experiences. (See below) *

I agree.

Kansas Code of Conduct

All Teacher education candidates (TECs) in a teacher education program participating in a field experience as a part of their degree program are expected to conduct themselves in accordance with the requirements and expectations of their degree program. TECs should not engage in unprofessional conduct or unlawful behaviors in accordance to KSDE's Kansas Educator Code of Conduct:

Licensure/ KS Ed Code of Conduct Brochure

In view of these expectations, teacher education candidates participating in a field experience who are unable to meet these academic standards, as judged by university faculty and cooperating teachers, may receive a failing grade and/or face possible removal from the field experience. For a more complete description of expectations and procedures for dismissal from field experiences see related documents in the Teacher Education Application Packet. By initialing this line you are stating that you understand the Kansas Code of Conduct and the expectations of all TECs conducing themselves in a professional manner.

Grounds for Dismissal from Field Experiences

Candidates in a teacher education program participating in a clinical experience as a part of their degree program are expected to conduct themselves in accordance with the requirements and expectations of their degree program. Candidates in a teacher education program should likewise not engage in unprofessional conduct or unlawful behaviors. In view of these expectations, students in a teacher education program participating in a clinical experience who are unable to meet these academic standards, as judged by faculty and cooperating teachers, may receive a failing grade and/or face possible removal from their particular clinical/field experience:

Candidates may not engage in any inappropriate interactions with pupils, guardians of pupils enrolled in the school, or school or university personnel during the clinical experience. If you feel you are under any pressure to engage in inappropriate social activity, contact your university supervisor.
Candidates' social interactions and communications, including use of cellular phones, Email, and the internet with school pupils, or guardians of pupils enrolled in the school, or school or university personnel, should be limited to those occurring in an official capacity at officially sponsored school events or sites.
Candidates may not be in the possession of or under the influence of alcoholic beverages, illegal drugs or dangerous weapons or substances on school property, nor with or in the presence of any school pupil(s).
Candidates may not use sexually explicit, obscene, profane, abusive, or derogatory language on school premises or at school sponsored events; nor may they suggest access to inappropriate material (e.g., on the Internet).
Candidates may not escort or transport pupils off school property unless accompanied by the cooperating teacher or another full-time employee assigned by the principal.
Candidates may not leave school early, be late to school or seminars, or have absences on a consistent basis.
Candidates may not falsify, forge, or alter any documents pertaining to academic records, including evaluation reports.

In addition, if at any time your conduct causes the cooperating teacher, the principal, or the university supervisor to determine that your presence in the classroom has become detrimental to the educational program of the pupils in the class, your actions will be reviewed by a field experience review team comprised of school and university officials and/or you may be asked to leave the school and your placement could be terminated by the University.

Should you be asked to leave the school based upon your behavior or your failure to perform at a satisfactory level, 黑洞社区 is not obligated to reassign you to another school. Failure to abide by these regulations may result in any of the following consequences: removal from field experiences, judicial action by 黑洞社区, legal action, and/or failure of course work.

I have read and am aware of 黑洞社区's Guidelines for Professional Conduct during Field Experiences and Grounds for Dismissal from Field Experiences.

Signature (Typed name will be accepted as signature)*

Date

Attestation of Eligibility

The Kansas State Board of Education requires that individuals who have been convicted of, or pleaded guilty to, any act punishable as a felony may not be certified to teach. Wichita State University is responsible for recommending individuals who have completed the teacher education program for certification as a teacher. Given this responsibility, it is asked that you read and sign the statement below.

If you are confident that you understand the standard, please answer the questions below and complete the "Attestation of Eligibility."

1. Have you ever been convicted of a felony?*

Yes

2. Have you ever been convicted on ANY crime involving theft, drugs, or a child?*

Yes

3. Have you entered into a criminal diversion agreement after being charged with any offense described in question 1 or 2?*

Yes

4. Are criminal charges pending against you in any state involving any of the offenses described in question 1 or 2?*

Yes

5. Have you had a teacher's or school administrator's certificate or license denied, suspended or revoked in any state?*

Yes

6. Is disciplinary action pending against you in any state regarding a teacher's or administrator's certificate or license?*

Yes

7. Have you ever been terminated, suspended, or otherwise disciplined by a local Board of Education for falsifying or altering student tests or student test scores? *

Yes

8. Have you ever falsified or altered assessment data documents, or test score reports required for licensure?*

Yes

If you answered 鈥淵es鈥� to any of the above, please describe your answer here.

ATTESTATION OF ELIGIBILITY

I,*

, attest to the College of Applied Studies at 黑洞社区 that I have not been convicted nor have I pleaded guilty for the violation of any law punishable as a felony and I can answer "no" to the questions 1-8 above.

Signature (Typed name will be accepted as signature)*

Date

To: Wichita State College of Applied Studies Teacher Intern

From: Jennifer Friend, Dean, College of Applied Studies

The College of Applied Studies regularly receives requests from school districts interested in contacting our student teachers for recruitment purposes. In order to assure that it is acceptable to you, as a prospective employee, to have your name, address, phone number and e-mail address released to these school districts, we need to have your written approval.

Please indicate below if you would like your name released to these school districts.

Yes, I am willing to have my name released to all interested districts.

Yes, I am willing to have my name released to all districts, except those noted below.

No, I do not wish to have my name released to districts.

Please do not release my name to the following districts:

I have already signed a contract with the school district below:

Position/ Level Preferred

Signature (Typed name will be accepted as signature)*

Date*