University of Pikeville Teacher Education Program

Transcription

1 University of Pikeville Teacher Education Program Application for Admission to any Teacher Education Program NAME DATE ADDRESS DATE OF BIRTH SS# - - HOME PHONE ( ) - WORK/CELL PHONE ( ) - UNIVERSITY RESIDENT ADDRESS PREFERRED ADDRESS ID# (LIST ADDRESS THAT YOU USE MOST) Classification: Junior Senior Post Graduate Gender: (optional) Male Female Ethnic Background: (optional) Non-resident Alien Black, Non-Hispanic Origin American Indian or Alaska Native Asian/Pacific Islands Hispanic White, Non-Hispanic Origin Unknown High School from which you graduate Date entered University of Pikeville - - Transfer Student: Yes No Current Advisor: Other Universities/Colleges Attended: Planned Field of Professional Preparation and Certification: Elementary P-5 Middle Grades 5-9 (5-9 candidates must choose one or two teaching fields) indicate below Secondary Education (8-12) (Indicate area of specialization below) Teaching Fields for Middle Grades (Select one or two): English Mathematics Science Social Studies Areas of Specialization for Secondary Education (Select one): Biology Chemistry English Mathematics Social Studies continued on back

2 Student Certification (Place a check in the appropriate box): 1. I have read and I understand the Criteria for Admission to Teacher Education and Student Teaching Program. 2. I understand that I must submit official transcripts on all college work completed to the Registrar s Office. 3. I understand that I may not enroll in upper division education classes (400 level) until I have been admitted to the University of Pikeville Education Program. 4. After being admitted to the Teacher Education Program, I understand that it is my responsibility to monitor my progress as related to satisfying GPA, course, and graduation requirements. 5. I understand that failure to make satisfactory progress may result in dismissal from the Teacher Education Program. 6. I understand that admission to the Teacher Education Program does not guarantee admission to the Student Teaching Program. 7. I understand the requirements for certification in the state of Kentucky. (Student Signature) If requested, I give/do not give (circle one), my permission for information regarding my progress in the University of Pikeville Teacher Education Program to be released to my parent(s) or legal guardian. (Student Signature) Date

3 PERSONAL AND PROFESSIONAL FITNESS FORM NAME: SOCIAL SECURITY NUMBER: SECTION II: PERSONAL AND PROFESSIONAL FITNESS (must be completed) Answer each question by circling "yes" or "no." If you answer "yes" to any question, you must submit a full explanation using a separate sheet of paper. 1. Have you ever held or do you currently hold a certificate, license, credential, or YES NO other document issued to you for practice as a professional educator by any jurisdiction (other than Kentucky) within the United States or abroad? If yes, enclose a copy of the certificate or provide the following: State or Jurisdiction Certificate Number Type Issue Date Expiration Date 2. Have you ever had a certificate, license, or other document YES NO issued to you for practice as a professional educator denied, suspended, revoked, or voluntarily surrendered? 3. Are you currently being reviewed or investigated for purposes or such YES NO action as stated in 2, or is such action pending? 4. Have you ever been dismissed, resigned, or been asked to resign/retire YES NO or discharged from a professional school position or military service for immorality, incompetence, willful neglect of duty, misconduct, or presenting false information toward obtaining the position? 5. Is any such action as stated in 4 pending? YES NO 6. Have you ever been convicted of a felony or misdemeanor (other than a YES NO moving traffic violation), been found guilty or entered a plea of nolo contendere (no contest), even if adjudication was withheld, in Kentucky or any other state? 7. Is any such action as stated in number 6 pending? YES NO I affirm and declare that all information given by me in this application form is true, and correct, and complete to the best of my knowledge. I understand that any misrepresentation of facts, by omission or addition, may result in the denial or revocation of my teaching certificate. Further, I understand the KRS provides that a teaching certificate may be revoked at any time upon determination that false information was presented toward obtaining a teaching certificate. I declare that I understand the standard for personal and professional conduct expected of a professional educator in Kentucky. SIGNATURE DATE

4 Professional Code of Ethics 704 KAR 20:680 Section 1. Certified personnel in the Commonwealth: 1) Shall strive toward excellence, recognize the importance of the pursuit of truth, nurture democratic citizenship, and safeguard the freedom to learn and to teach; 2) Shall believe in the worth and dignity of each human being and in educational opportunities for all; 3) Shall strive to uphold the responsibilities of the education profession, including the following obligations to students, to parents, and to the education profession: TO STUDENTS TTTO PARTO PARENTS TO EDUCATION PROFESSION Shall provide students with Shall make reasonable effort Shall exemplify behaviors professional education services in a to communicate to parents which maintain the dignity non-discriminatory manner and in information which should and integrity of the consonance with accepted best be revealed in the interest of profession. practice known to the educator. the student. Shall respect the constitutional rights of all students. Shall take reasonable measures to protect the health, safety, and emotional well-being of students. Shall not use professional relationships or authority with students for personal advantage. Shall keep in confidence information about students which has been obtained in the course of professional service, unless disclosure serves professional purposes or is required by law Shall not knowingly make false or malicious statements about students or colleagues. Shall refrain from subjecting students to embarrassment or disparagement. Shall not engage in any sexually related behavior with a student with or without consent, but shall maintain a professional approach with students. Sexually related behavior shall include such behaviors as sexual jokes; sexual remarks; sexual kidding or teasing; sexual innuendo; pressure for dates or sexual favors; inappropriate physical touching, kissing, or grabbing; rape; threats or physical harm; and sexual assault. Shall endeavor to understand community cultures and diverse home environments of students. Shall not knowingly distort or misrepresent facts concerning educational issues. Shall distinguish between personal views and the views of the employing educational agency. Shall not interfere in the exercise of political and citizenship rights and responsibilities of others. Shall not use institutional privileges for private gain, for the promotion of political candidates, or for partisan political activities. Shall not accept gratuities, gifts, or favors that might impair or appear to impair professional judgment, and shall not offer any of these to obtain special advantage. Shall accord just and equitable treatment to all members of the profession in the exercise of their professional rights and responsibilities. Shall keep in confidence information acquired about colleagues in the course of employment, unless disclosure serves professional purposes or is required by law. Shall not use coercive means or give special treatment in order to influence professional decisions. Shall apply for, accept, offer, or assign a position or responsibility only on the basis of professional preparation and legal qualification. Shall not knowingly falsify or misrepresent records of facts relating to the educator s own qualifications or those of other professionals. I hereby acknowledge that I have read the Kentucky s Professional Code of Ethics for school personnel in Kentucky and agree to abide by and exhibit the behaviors described therein. Name (print) Signature Date

5 University of Pikeville Teacher Education Program Certification Information Acknowledgement I hereby acknowledge that I have been given information about the requirements necessary to obtain certification for teaching in the state of Kentucky. Student Name (please print) Student Signature Date

6 University of Pikeville Teacher Education Program Student Handbook Acknowledgement Form I hereby acknowledge that I have received a copy of the current edition of the University of Pikeville Teacher Education Student Handbook. I further acknowledge that I will responsibly become familiar with and abide by the policies contained in that handbook. Student Name (please print) Student Signature Date

7 Candidate, please check box 1 or 2. Recommendation for Admittance to the University of Pikeville Teacher Education Program Three Required 1. The candidate has chosen to retain his/her right of access to this reference. Therefore, this reference may be read by the candidate upon request. 2. The candidate has chosen to waive his/her right of access to this reference. Therefore, this reference may not be read by the candidate. Candidate s Name Candidate s Signature Please Print Completed by Date Please Print Based on your experience, please rate the applicant as follows: Above Please indicate by checking Outstanding Average Average Fair Below Average Unknown Maturity in social and intellectual areas Regularity of attendance Responsibility in areas of morality Rapport with fellow students and faculty Acceptance of constructive supervision Willing to cooperate Personal appearance Use of English, verbal Use of English, written Punctuality Attitude toward course work Knowledge of subject matter Projected success in teaching Additional Comments: I recommend the applicant for admission to the Teacher Education Program. I do not recommend the applicant for admission to the Teacher Education Program.