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
click to sign
signature
click to edit
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