Year Long Cooperating Teacher Application

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Jacksonville State University

Office of Clincal Experiences

CEPS Complex, 115 College Street SW, Jacksonville, AL 36265

(256) 782-5859

CT Website

clinicalexperiences@jsu.edu

Year Long Cooperating Teacher Application

General Information

Term you are sponsoring:

Additional term to sponsor:

Type of student you are interested in sponsoring:

Would you like to be considered as a recurring cooperating teacher each year?

Requirements for hosting teacher candidates

Practicum Cooperating Teachers must:

have at least 3 or more years of experience in their filed
have administrator's approval

Internship Cooperating Teachers must:

be certified in the student's teaching field
have at least 3 or more years of experience in their field
hold a Masters in the student's teaching field OR be Nationally Board Certified (NBCT) *expectations can apply
have administrator's approval

Contact Information

First Name

Middle Name:

Last Name

Email:

Phone Number

Work Email:

Work Number

Date of Birth:

SSN:

Do you teach at more than one school in your school district?

Yes

School 2

School 3

Education Information

T-Cert Number

Lookup your T-Cert (TCH) Number

Degree

Years of Experience

as a certified teacher of record for the current academic year (number only)

Certfications

Please list each area of certification below and mark the highest certification level you have earned in each

Certification Area 1

Certification Level 1

Certification Area 2

Certification Level 2

Certification Area 3

Certification Level 3

Certification Area 4

Certification Level 4