Note: Completed application must be submitted typed or neatly printed in black to the School of Education Office Coordinator in G212.
Part I Teacher Candidate Personal Data
This form is sent to you directly from the School of Education. Fully complete the background information and
return to the School of Education Office Coordinator electronically. Additionally, prepare a professional resume to
send along with this form. This page and a copy of the resume are sent to the cooperating principal(s) and
teacher(s) to supply general information about you.
Please note - After your assignment is announced, you are expected to write a letter of introduction to your
cooperating teacher(s). If you need assistance with this letter, contact Career Services or the Director of Teacher
Education for help.
Part II Background Check
This form while it repeats information from Part I, must be fully completed. Background checks are required on all
teacher candidates and interns.
Part III Placement Information
It is imperative that students share any circumstances/suggestions regarding your placement for teacher
candidacy.
Part IV Responsibilities
It is important that you read the following carefully. You must demonstrate you readiness for teacher candidacy
and fully accept this responsibility. If you are having some doubts about your preparation, please contact your
advisor or the Director of Teacher Education for counsel.
Disclosure Questionnaire Please complete both pages as directed. (after part V)
Part V Documentation of Exit Requirements Note: Only some information is completed by the candidate.
1. Complete personal and academic information.
2. Prepare portfolio to be presented/submitted at the time of meeting with the 6FKRRORI(GXFDWLRQ. (See
Appendix F, Portfolio Guidelines and Rubric)
3. Note your scheduled portfolio presentation times. Dates and times are posted on the Director of Teacher
Education's
door, outside of the Education office and/or with WLC calendar planner.
4. A faculty recommendation: Submit a faculty members name from the major/minor who can best attest to your
academic preparation. The School of Education contacts that faculty member to directly respond.
5. Present your portfolio. This is a presentation to ascertain your readiness for teacher candidacy. The candidate
for this clinical experience must demonstrate readiness in knowledge, skills, and disposition for teacher
candidacy. The department members complete the “assessment of readiness form at the portfolio meeting.
Presentation and Portfolio Release Form
Please complete and return with your Application for Teacher Candidacy.
Health Form WLC form attached which must be completed within 30 days of the first day of teacher candidacy. The
Wisconsin Lutheran College School of Education cannot in good conscience allow teacher candidates to begin
their professional semester without first obtaining a negative TB test. These health results are shared with the
cooperating schools.
*Copy all pages for your own records.
INSTRUCTIONS FOR COMPLETING THE
APPLICATION FOR TEACHER CANDIDACY
(DUE DATES: FALL CANDIDACY-FEBRUARY 1, SPRING
CANDIDACY-SEPTEMBER 15)
Application for Teacher Candidacy
Wisconsin Lutheran College 6FKRRORIEducation
_________________________ ___________________ __________________ Date__________________
Name
Last First Middle
Students are notified officially of their assignments prior to or at the orientation meeting scheduled before the start of
school. Students register at the regular registration
Grade Level Certification Specialization Area
Early Childhood/Middle Childhood _____ ___________________ certifiable: ____ yes ____ no ( Praxis II met)
Middle Childhood/Early Adolescence _____ ___________________ certifiable: ____ yes ____ no ( Praxis II met)
Early Adolescence/Adolescence _____ ___________________ certifiable: ____ yes ____ no ( Praxis II met)
Early Childhood thru Adolescence(WR) _____ ___________________ certifiable: ____ yes ____ no ( Praxis II met)
Requirements
1. Academic
a. A minimum overall GPA of 3.0 in the major (subject and/or professional sequence) and minor.
b. A minimum grade of BC in all teacher education courses (removal of all failure or D grades)
c. No “Incomplete” grades or unfinished online or correspondence courses upon start of teacher candidacy.
d. No Wisconsin Lutheran College probation of any kind.
2. Successful completion of all courses for licensure area.
3. Successful completion of all clinical experiences.
4. Successful participation in Portfolio Preparation Seminar
5. First Aid/CPR certificate (attach documentation if not contained in your EDU file).
6. Liability Coverage
________ I have reliable transportation to and from my teacher candidacy assignment and the vehicle I will be using
is fully insured.
________ I declare that, during my teacher candidacy assignment, I am fully covered by personal liability insurance
provided by _________________________________________________________________________.
Believing that I have met the above requirements, I hereby apply for admission to EDU 495 Teacher Candidacy.
______________________________________________________________ _______________________
Signature of Teacher Candidate Date
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I. Teacher Candidate Personal Data
This form along with a copy of your resume is sent to your cooperating school(s).
Name:
Major / Minor (if applicable):
High School Attended:
Dates:
Other Colleges Attended:
Dates:
Student Address at College:
Phone:
Email:
Student Home Address:
Phone:
Email:
Employment and volunteer experiences:
ActivitiesInterests, hobbies, college and community organizations, teams, music groups:
Teaching experiences prior to teacher candidacy:
Travel experiences:
Permission to copy:
Wisconsin Lutheran College has my permission to give a copy of this Teacher Candidate Personal Data Form to school
personnel concerned with making teacher candidacy placements.
Signature ____________________________________________________ Date____________________________
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II. Application For Clinical Experiences: Background Check
NOTE: This information is necessary to complete the background check. Your birthdate and social security number are
not given to other parties.
Fall 20 ______ Spring 20 ______
Check One:
Name: ___Mr. ___Mrs. ___Miss ___Ms.______________________ _______________ ____ __________________
Last First M.I. Former Name(s)
Alias: ______________________________
School Address:______________________________________ _________________________ _____ __________
Street City State Zip
Home Address:_____________________________________ __________________________ ______ __________
Street City State Zip
Birthdate: __________________ SS # ________________________ Ethnicity: ____________ Gender: ___________
Phone: ________________________(Home) ________________________(Work) _______________________(Cell)
OUT OF STATE
Have you lived, worked or studied outside of the state of Wisconsin in the past 20 years? _______ yes ________no
If yes, please give specific address(es) and circumstances.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
EDUCATION: Name City & State Dates Attended
High School ___________________________________________________________________________________
Other Colleges _________________________________________________________________________________
______________________________________________________________________________________________
Certification Area: _____________________________________________________________________________
Release Signature
I hereby understand that the above information is being used to investigate my background.
________________________________________________ _____________________________
(signed) (date)
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III. Teacher Candidate Placement Information
Circle One:
Name: ___Mr. ___Mrs. ___Miss ___Ms.______________________ _______________ ____ __________________
Last First M.I. Former Name(s)
School Address:______________________________________ _________________________ _____ __________
Street City State Zip
Home Address:_____________________________________ __________________________ ______ __________
Street City State Zip
Phone: _______________________ (Home) __________________________ (Work) ______________________(Cell)
E-Mail: _____________________________________ Licensure Area(s):_____________________________________
Grade levels at which I have had clinical experience are as follows (Indicate subject area and grade level):
_________________________________________________________________________________________________
Student Request
In your teacher candidacy placement, your preferences regarding the type of school and classroom setting
are important. Please indicate below any special considerations that should be made in placement, school or
district preferences, or type of school, etc. Special requests are considered to the extent that it is possible as
well as desirable for your professional growth. Provide any supporting detail. (Ref: App.E - T.E. Handbook)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
________ Check here if you are willing to participate in co-curricular activities. Describe below.
Please state briefly any special requests, accommodations, situations or circumstances pertaining to your
teaching assignment:
FEES: All teacher candidates/interns: If accepted for teacher candidacy, you must pay the following: $25 to cover costs
of background check and partial supervision costs. Fee must be paid in full prior to teacher candidacy.
Teacher Candidate Initial________
B. Interns Only: If an internship becomes available for you, are you willing to do the following:
1. Pay for a license ($50 on-line): _______ yes _______ no
2. Pay $200 DPI processing fee: _______ yes _______ no
3. Make arrangements to be interviewed: _______ yes _______ no
4. Fulfill any other district and WIP requirements: _______ yes _______ no
NOTE: If selected for an internship, this means a total fee of $275.00 which includes the $50 on-line license fee.
Teacher Candidate Initial ________
CAUTION: For all programs leading to a certificate or license to teach or requiring field placement, e.g., field experience,
and teacher candidacy, applicants for admission must disclose whether they have been denied, revoked or suspended in
any state for reasons other than insufficient credits or courses. The existence of a criminal record or denial, revocation or
suspension does not constitute an automatic bar to admission and is considered only as it substantially relates to the
duties and responsibilities of the programs and eventual licensure.
IV. Teacher Candidate Responsibilities Agreement
Please read, initial after each point and sign below:
If I am accepted in the Teacher Candidacy Program, it is understood that I am responsible for:
INITIAL
1. Keeping a continuous and accurate check of my overall program as to the required
courses in my Major(s) and Minor(s) area, the general education requirements, and
all other requirements for graduation and certification. ________
2. Arranging for a visit to the cooperating school upon confirmation of the assignment for
the purpose of meeting and conferring with the principal and cooperating teacher(s)
with whom I am assigned during the teacher candidacy program. ________
3. Thoroughly preparing all unit and daily lesson plans that are to be submitted to the
cooperating teacher for appraisal and approval. ________
4. Being punctual and attending school every day; communicating with the principal,
teacher, and the supervisor in the event of any absence or unavoidable tardiness. ________
5. Participating in such professional activities, including parent meetings and sponsorship
of school activities, as requested by the principal and cooperating teachers. ________
6. Completing the daily journals and any other required reports, regularly, thoroughly,
and on time. ________
7. Attending EDU 496 Seminar for Teacher Candidacy and participating as a professional. ________
8. Conducting myself, both in the school and community, in a manner that reflects
favorably upon Wisconsin Lutheran College, the teaching profession and, Christian character
and integrity. ________
9. Planning for and preparing of my Stage 4-Completion Portfolio to clearly demonstrate
growth in my knowledge, skills, and dispositions as brought forth through the teacher candidacy
experience; I understand that it is my responsibility to demonstrate student
learning as a result of my teaching. ________
10. Collecting samples/examples of materials such as journal entries, assessment,
communication, lesson plans, and instructional technology which demonstrate
growth over time and contribute to instructional effectiveness. ________
(Points 9 and 10 must be presented at the Exit Meeting with your supervisor.)
I understand the importance of teacher candidacy and my commitment to both the cooperating teacher(s) and the
students. I assume responsibility
for participating in college activities and/or working part time while a teacher candidate
may affect my success in the classroom.
__________________________ _______________________________________________
Date Signature of Teacher Candidate
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V. Documentation of Exit Requirements
Student Name: ____________________
Coursework Information: Supply ONLY
major/minor labels; the rest is completed by the School of Education
administrative assistant.
1. Academic Major: _________________________
Completion of coursework (as of end of semester) ____ yes ____ no
Grade Point Average (approximate GPA) __________
2.. Education Major (ECH/MC; MC/EA; EA/A; WR): _______________________________________________
Completion of coursework (as of end of semester) ____ yes ____ no
Grade Point Average (approximate GPA) __________
3. Academic Major/Minor: _________________________________
Completion of coursework (as of end of semester) ____ yes ____ no
Grade Point Average (approximate GPA) __________
Specific Criteria: This section is completed by School od Education administrative assistant.
1. Health Form
Completion within required time frame
____ yes ____ no
General Health--satisfactory
____ yes ____ no
Accommodations/Limitations to be shared with cooperating school ____ yes ____ no
Specifics:
TB Test Results--acceptable ____ yes ____ no
2. Disclosure Questionnaire Completion ____ yes ____ no
3. Background check satisfactory ____ yes ____ no
Faculty Recommendation: Supply ONLY the name of a professor. The School of Education administrative assistant
forwards this form to that professor.
Faculty selected by the teacher candidate: ____________________________________________
(Approval is based on performance and contribution in coursework.)
In my best estimation, the above named candidate does/does not (circle one choice) have the content
knowledge/skills/dispositions essential for teacher candidacy.
Signed: ______________________________________________ Date: ___________________________________
Additional Comments:
Information that is in italics is supplied by the student.
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Education Faculty Assessment of Readiness
__________
The candidate shows above average potential for a successful teacher candidacy experience.
__________
The candidate shows average potential for a successful teacher candidacy experience.
__________
The candidate shows below average potential for a successful teacher candidacy experience.
The School of Education makes recommendation of the following:
_____ Revise and re-present the portfolio, addressing two areas of weakness:
_____ Observe master teachers, concentrating specifically on:
_____________________________________________________________________________
_____________________________________________________________________________
_____ Enroll in _______________________________________________________________________.
_____ Withdraw from application for teacher candidacy.
____________________________________________ is hereby accepted for/denied to teacher candidacy.
(Student Name)
This is to certify that the following members of the School of Education have examined and evaluated the above
criteria.
______________________________________________ ___________________ __________________________
Signature of School of Education Member
Date Position
________________________________
______________ ___________________ ___________________________
Signature of School of Education Member
Date Position
________________________________
______________ ___________________ ___________________________
Signature of School of Education Member
Date Position
________________________________
______________ ___________________ ___________________________
Signature of School of Education Member
Date Position
________________________________
______________ ___________________ _________________________
Signature of School of Education Member Date Position
______________________________________________ ___________________ ___________________________
Signature of School of Education Member
Date Position
________________________________
______________ ___________________ __________________________
Signature of School of Education Member
Date Position
________________________________
______________ ___________________ __________________________
Signature of School of Education Member
Date Position
Additional
Comments:
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DISCLOSURE QUESTIONNAIRE FOR ADMISSION
TO
THE TEACHER EDUCATION PROGRAM/TEACHER CANDIDACY
(Must be completed at time of entry into EDU 201 and/or first off-campus
field experience. A second form must be completed prior to teacher candidacy.)
INSTRUCTIONS
The School of Education r equires app licants for ad mission t o pr ograms l eading to a c ertificate or l icense t o teach, or
requiring f ield placement, e .g. field e xperience, e lementary and /or s econdary methods, hu man relations p racticum, or t eacher
candidacy to complete the following confidential
Disclosure Questionnaire. The Disclosure Questionnaire is distributed by and returned
to the Director of Teacher Education and is kept separately from your general WLC student file. They are viewed only by the School of
Education. The School of Education may need to collect additional information to make their determination. Pertinent decisions
and comments are recorded and placed into the student file.
Failure t o c omplete t he D isclosure Questionnaire, f alsification or omission of i nformation relevant t o t hese que stions constitutes t he
denial of admission or termination of admission if the falsification or omission is discovered after admission or placement.
An affirmative response to an item does not necessarily mean that a student is denied for admission, but is contacted to explain the
circumstances leading to the affirmative response. In addition, the School of Education may request further information from
appropriate sources. Consent to obtain this information is necessary to continue.
The School of Education
takes the information provided/obtained into account in determining whether to admit the student to the
program, to postpone admission, or to place special conditions on admission or to provide special accommodations.
In the e
vent a s tudent i s denied admission to the pr ogram based on r esponses to the questions below, the student has t he right to
appeal that decision. Notice of appeal procedure is forwarded to the student in the event of a denial. A copy of the appeal procedure is
also available from the office of the Dean of the College of Professional Studies and WLC
Student Handbook.
INFOR
MATION
Name __________________________________________ Student ID _________________________________
(First) (M.I.) (Last)
SS # ______________________________________
Previous Name (If Any) ____________________________
Birth date __________________________________
Alias/Maiden ____________________________________
Ethnicity __________________________________
Home
Address _____________________________ City _____________________ State _______________ Zip ____________
Campus Address ___________________________________ _____________________ _____ ____________
Street Address City State ZIP
My signature hereon indicates my understanding that misrepresentation of factual information on this Disclosure Questionnaire is cause
for denial or revocation of admission to the WLC School of Education, denial
, termination or retraction of field experience or
teacher
c andidacy pl acement, or de nial or r evocation of certification. I al so he reby aut horize W LC t o c onduct t he n ecessary
background check.
_______________________________________________ _________________________________________
Student Signature Date of Signature
Please complete both pages and return to: Director of Teacher Education
Room G236
Wisconsin Lutheran College
8800 W. Bluemound Road
File: Student Education File Milwaukee, WI 53226
100
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DISCLOSURE QUESTIONNAIRE
Name ______________________________________SSN__________________________Date ___________________
Attach additional pages as necessary to fully respond to questions below.
Dept.
Initial
1. Have you ever had a teaching license?
Has teaching licensure been denied/revoked/suspended in any state in the United States for
reasons other than insufficient credits or courses? If “Yes,” please describe situation:
Is revocation or suspension pending? If Yes,” please describe situation:
Yes No
Yes No
Yes No
_______
_______
_______
2. Have you ever been suspended, expelled, placed on probation (other than for collegiate
skills) or otherwise di sciplined by an y c ollege or uni versity or from any p rogram o f a
college or uni versity, e ither for ac ademic or o ther reasons? I f “Yes
, pl ease d
escribe
situation:
Yes No
_______
3. Have you ever been terminated for cause from an employment situation? If “Yes,” please
describe:
Yes
No
_______
4. Have you ever been suspended, discharged or otherwise disciplined for conduct relating
to the health, welfare, safety, or education of any pupil?
Yes No
_______
5. Have you ever been suspended, discharged, or otherwise disciplined for conduct relating
to the breach of commonly accepted moral or ethical s
tandards?
Yes No
_______
6. Have you ever been investigated for any conduct listed in Questions 4 and 5 above?
Yes N
o
_______
7. Have you ever been under investigation, involved in, convicted of, pled guilty to, pled no
contest to, or forfeited bail for any criminal conduct under law or ordinance, or is any such
situation
pending, excluding minor traffic violations? If “Yes,” please describe situation:
(Note: T he existence of a c riminal r ecord or d enial, r evocation or s uspension of a l icense d oes n ot
constitute an automatic b ar t o admission and is considered only as t hey s ubstantially r elate t o t he
duties of the program and eventual license.)
Yes No
_______
8. Have you ever been reported to the state school superintendent for any conduct listed in
the above questions?
Yes No
_______
9. Are you able to perform the duties and responsibilities of a field experience or practicum,
teacher candidacy, or internship with or without reasonable accommodati
on?
If Yes, with accommodation is checked, please describe with what reasonable conditions or
circumstances you are able t o carry out the duties and r esponsibilities of t he position which
you seek:
(Note: Wisconsin Lutheran College makes reasonable accommodations.)
Yes w/ accommodation
Yes w/o accommodation
No
_______
******************************************************************************************
A CRI MINAL HI STORY BA CKGROUND C HECK b ased o n i nformation on t his form w as p erformed through t he WISCONSIN
DEPARTMENT OF JUSTICE CRIME INVESTIGATION BUREAU (http://wi-recordcheck.org/).
DATE: __________________ Order Number: _______________ RESULTS: ________________________________________
CHECK PERFORMED BY: _____________________________ - Wisconsin Lutheran College - School of Education
8800 West Bluemound Road
Milwaukee, Wisconsin 53226
____________________________________________
Signature of WLC School of Education Director
Wisconsin Lutheran College
Presentation and Portfolio Release Form
With this RELEASE FORM the WLC School of Education seeks your permission to use all or a portion
of your presentation and/or portfolio for observation/training purposes within WLC.
If you prefer NOT to have your presentation and/or portfolio used,
you may also indicatethat preference on this form.
Release Form
Name (print) _______________________________ School: ___________________________________
Address: __________________________________ Address: __________________________________
__________________________________________ __________________________________________
Semester/Year of Teacher Candidacy/Professional Development Experience/Internship: _____________________
Taped Presentation
Permission is given for my taped presentation to be used for observation/training purposes.
_____________________________________________________ Date _________________________
(signature)
Date of Presentation: ________________________________________________________________________
Permission is NOT given for my taped presentation to be used for observation/training purposes.
_____________________________________________________ Date _________________________
(signature)
Electronic Portfolio
Permission is given for my electronic portfolio to be used for observation/training purposes.
_____________________________________________________ Date _________________________
(signature)
Permission is NOT given for my electronic portfolio to be used for observation/training purposes.
_____________________________________________________ Date _________________________
(signature)
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