Fill - Free fillable Ate-application-packet Application for Admission to Teacher Education PDF form

Application for Admission to Teacher Education

Albany State University – Educator Preparation Program

Candidates please follow all steps below to complete your application.

Incomplete applications will not be accepted.

STEP 1:

Create My PSC and GACE.ETS Account (see attached instructions on how to set-up

account)

STEP 2: Register for GACE Program Admissions

MyPSC account and select Assessments at the top of the

MyPSC home page. Follow the steps below to request or confirm eligibility to

test:

2. Select the reason why you want to take the GACE assessment (see below).

a. GACE Program Admissions –

1. Log in to your

Select reason #1

#1 I am testing to satisfy the

You must add the program you are enrolled

Program Admission assessment

in or seeking admission into as a score

requirement.

recipient.

b. GACE Content only: If you are enrolled in or have completed an

approved program, you will see the list of programs and providers

where you have claimed enrollment and your status for your eligibility

to test for the program(s). If you do not see any programs and

providers listed, it means you have not claimed your enrollment. See

Claiming Your Enrollment Record below.

3. Select the assessment for which you are requesting eligibility to test from the

drop-down menu.

4. Click the ADD button.

5. Confirm your choices by typing “yes” in the space provided and then

click FINISH. (You can click QUIT to cancel your selection.)

6. Your profile and eligibilities will be transmitted to ETS.

7. At the bottom of the Assessments page is a list of your active and pending

eligibility requests and their status. Note: Program providers are notified via

email of pending requests for eligibility.

Teacher Education – ATE Application Package Revised: November 2016 LJ

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STEP 3:

Register for GACE Ethics Entry (350)

All updates to your information must be completed through your MyPSC account on

the GaPSC website prior to registering for the assessment.

How to Register

Registering for one of the Georgia Ethics assessments is a four-step process:

1. Create or update your MyPSC account on the GaPSC website and enter your

reason for testing.

2. The GaPSC sends your profile and eligibility information to ETS.

3. ETS sends you an email with a link to the Georgia Ethics assessment system.

4. Access the Georgia Ethics assessment system, select Test Takers under

Registration, create your account, and register and pay for the assessment.

Program Entry candidates: You must add your program provider as a score recipient

when you register or they will not receive notification that you have completed the

assessment.

There are no specific testing dates or testing windows for the Georgia Ethics

assessments, but you must create or update your MyPSC account and enter

your reason for testing before you can register.

You are responsible for ensuring that the first and last name in your MyPSC

account match the name you enter in the Georgia Ethics assessment system. The first

and last name in this account will be on your certificate of completion for the

assessment.

STEP 4: Submit application for review

 Meet with assigned advisor to review the application & make revisions as

necessary

 Advisor will submit application to Office of Teacher Admission

NOTE: Applications will be accepted only from academic advisors

Teacher Education – ATE Application Package Revised: November 2016 LJ

Page2

The Admission to Teacher Education

Application Package

Assemble in the following order:

 Application (Check Front and Back)

 Practitioner Demographic Data (Front Only)

 Candidate Self Evaluation (Front Only)

 Code of Ethics (Front and Back)

 Essay Analysis and Critique Rubric (Name and Ram ID)

 Two Recommendation Forms from (Front Only)

 Transcripts (2.50 GPA)

 GACE Program Admissions Scores OR substitute scores, SAT, ACT,

GRE, Praxis

 Criminal Background Check application

o NOTE: You must pass the Criminal Background Check every

semester you are enrolled in 3000-4000 level classes in order to

maintain your status as a Candidate in the Teacher Education

Program.

 GACE Ethics Entry Exam Certificate (Beginning Fall 2014)

 Pre-Service Certificate Application completed (Beginning Fall 2014)

 Copy of Driver’s License or ID

 Liability Insurance i.e. GAE or PAGE student membership (copy)

 Professional Disposition Statement signed by student.

Teacher Education – ATE Application Package Revised: November 2016 LJ

Page3

Candidate Requirement

Step 1: Create MyPSC Account

Go to the link below and register for a My PSC Account

https://mypsc.gapsc.org/Register.aspx

 Select: “Enrolled in Georgia Educator Preparation Program”

 Select: “To take GACE assessment”

o Certification Identification # will be provided; keep this number for your

records. You will also need it to create GACE Testing account.

Step 2: Create GACE Testing Account

Register for an ETS GACE Test account. This allows you to take the GACE Program

Admission, Ethics, and GACE Content test (Must have My PSC account first before

create GACE Testing account)

Click here to create account www.GACE.ets.org

 Select “Sign-In” (top right of website)

 Go to “New User” area

 Select “Create Account”

 Save log-in credentials

Register and complete Program Admissions Test (Reading, Writing, Math) Assessment;

 Dates and times test is available will be shown when you register

 Print a copy of passing scores and submit with application

Register and Complete GACE Ethics Entry

 Assessment is anytime and anywhere

 Assessment cost $30

 Print Certificate

of Achievement and submit with application

Teacher Education – ATE Application Package Revised: November 2016 LJ

Page4

APPLICATION FOR ADMISSION TO THE EDUCATOR PREPARATION PROGRAM

Applicant Information Must be admitted to ASU

RAM I D

Name

ADDRESS

City:

State:

ZIPCODE:

PREFERRED PHONE

E-MAIL

HOME PHONE

CERTIFICATION INFORMATION CHECK ALL THAT APPLYCcc

MYPSC.COM ID #

AREA:

SEEKING

 EARLY CHILDHOOD

 MUSIC EDUCATION

 HEALTH AND PHYSICAL

EDUCATION

 SCIENCE (BROAD BASED FIELD)

 SPECIAL EDUCATION

 OTHER:

 MIDDLE EDUCATION (Place a

for your PRIMARY-P and S

SECONDARY for

CONCENTRATION)

 LANGUAGE ARTS

 MATH

 SCIENCE

 SOCIAL STUDIES

 DEGREE

 MINOR IN EDUCATION NON-

CERTIFIED

 CERTIFICATION ONLY

 T4-BACHELOR

 T5-MASTERS

REQUIREMENTS (Attach documents of verification for all applicable items below.)

1. _______ENGL 1101 12. ______Pre-Service Certification Application

2. _______ENGL 1102 13. ______Copy of Driver’s License or ID

3. _______EDUC 2110 14. ______Letters of Recommendation (2) From any

4. _______EDUC 2120 current or former ASU Faculty

5. _______EDUC 2130 15. ______Applicant Self Evaluation

6. _______ASU Hours Earned 16. ______Applicant’s Essay

7. _______Institutional GPA 17. ______Criminal Background Check Application

8. _______Transfer GPA 18. ______GACE (Reading, Writing, Math) Program

9. _______Transfer Hours Admissions Scores (250 passing) or IF GACE

10. _______Program of Study/Checksheet EXEMPTION: ACT 43 MATH/ENGLor

11. _______GACE Ethics Entry Exam

SAT 1000 VERBAL/MAT

Advisor Signature: _______________________________________________________________ Date: _________

(I have reviewed and verified evidence for Performance Measures in Performance Measures in

Part III)

FOR ADMISSION TO TEACHER EDUCATION OFFICE USE ONLY

Approved by ____________________________________________________________ Date______________

Teacher Education – ATE Application Package Revised: November 2016 LJ

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APPLICANT

ADVISORS

EADLINE FOR SUBMISSION OF APPLICATION PACKET

APPLICATION PROCESS

THE ADMISSION OFFICE OF THE EDUCATOR PREPARATION PROGRAM RESERVES THE RIGHT TO CHANGE PROVISIONS

LISTED IN THE CATALOG AND OTHER STUDENT-INFORMATION DOCUMENTS IN ADHERENCE TO CHANGES MANDATED

BY FEDERAL, STATE AND LOCAL AGENCIES THAT GOVERN TEACHER EDUCATION PROGRAMS

The application forms are available in The Admission Office of the Educator Preparation Program, Billy C. Black

Building, Room 252. The applicant must initiate the application process by completing the information in Part I, Part

II, and Part III (if applicable) of the application, attaching verification documents for each section, and presenting

the complete packet to the assigned advisor.

Advisors facilitate the application process to ensure that the application is signed and complete the application.

Advisors should submit the applicant’s packet to the Coordinator of Admissions to Teacher Education.

CERTIFICATION OFFICER FOR TEACHER EDUCATION

The Certification Officer for the Educator Preparation Program approves or denies applications. If denied, the

Certification Officer will return the application packet, with explanation, to the Advisor within five working days of

receipt of the application packet. Upon approval the Certification Officer provides the applicant a letter of

admittance by ram e-mail.

The applicant must initiate the application process one semester prior to the semester in which they expect to enroll

in 3000 or 4000 level Teacher Education courses.

GPA

A GPA of 2.50 or above must be maintained for good standing in the Teacher Education program and is required

for certification and Graduation You must have a 2.50 GPA to participate in Student Teaching or Internships. A GPA

of 2.75 or better is required for Second Chance applicants. .

BEGINNING SCHOOL EXPERIENCE

All students are required to spend two weeks in a public school to observe/participate at the beginning of the

school year. Students must apply for the beginning school experience during the spring semester prior to the

academic year they are scheduled to student teach, whether student teaching in the fall or the spring. They must

complete this non-paid volunteer experience as a staff member in a public school setting. Approval and

arrangements for the beginning school experience are made with the public school by the Director of Clinical

Experiences. Service for one year as a paraprofessional may substitute for the beginning school experience.

EDUC 3403: PREPARATION FOR TEACHING

Approval from the ASU coordinator of student teaching is required for enrollment in this class. Students should take

this course in THE SEMESTER before STUDENT TEACHING or INTERNSHIP. You must pass your Criminal Background

Check and maintain the 2.50 GPA in order to Student Teach or Intern.

All Candidates must pass all areas of the GACE in their program of study prior to Graduation.

EDUC. 2199 Orientation to Teacher Education

Candidates will be enrolled in this course upon acceptance and must complete the course in order to remain in

the Teacher Education Program.

I read and understand the above policy statements about the procedural process for admittance to the Teacher

Education Program at Albany State University.

Applicant’s signature: _____________________________________________ Date: ____________________

Teacher Education – ATE Application Package Revised: November 2016 LJ

Page6

Practitioner Demographic Data

Directions: Please select the appropriate choice from the following items.

Certification Level:

 P-5

 4-8

 7-12

 BS Ed. T-4

 MS Ed T-5

Area(s) of Certification

 English Education

 Early Childhood Education

 Math Education

 Middle Grades Education

 Broad Field Science Education

 Social Science Education

 Special Education

 Interrelated/ M Ed

 Intellectually Disabled BS Ed

 Other:

 Science Education

 Health and Physical Education

 Music Education

 Other School Personnel

 Principal

 Assistant Principal

 School Counselor

Age:

 Under 21

DOB: ___________

Gender:

 21-30  31-40  41-50  51-59  59+

Ethnicity:

 Male  Female

 White/Non-Hispanic

 Hispanic

 Black/Non-Hispanic

 American Indian or Alaskan Native

 Asian/Pacific Islander/East Indian

 Multi-ethnic

Teacher Education – ATE Application Package Revised: November 2016 LJ

Page7

Candidate Self-Evaluation

Rating scale: 1 – Unacceptable 2 – Acceptable 3 – Targeted

Score

Commitment to students and their learning.

1. I exhibit personal and professional integrity.

1 2 3

2. I respect the learners he/she teaches.

1 2 3

3. I provide multicultural learning environments.

1 2 3

4. I hold high expectations for all learners.

1 2 3

5. I respond appropriately to the needs of each individual learner.

1 2 3

6. I create learning environments that support the development of every learner.

1 2 3

Knowledge & Skills

7. I demonstrate knowledge of the content required for his/her teaching area.

1 2 3

8. I use appropriate oral and written language skills to communicate content.

1 2 3

9. I implement effective instructional practices.

1 2 3

10. I use technology to support learning experiences for students.

1 2 3

Managing and monitoring student learning.

11. I design instruction that is guided by principles of human growth and development

1 2 3

that is appropriate for all learners.

12. I design instruction that is guided by the Georgia Quality Core Curriculum and/or other

appropriate standards.

1 2 3

13. I design instruction that incorporates parental involvement of all learners.

1 2 3

14. I use multiple methods of assessing student learning.

1 2 3

15. I recognize the characteristics of children with exceptional needs and follows

appropriate processes for student referrals.

16. I attain student achievement goals on specified learning outcomes.

1 2 3

Personal Reflection

17. I use feedback to improve on learning and practice.

1 2 3

18. I participate in opportunities for further professional development.

1 2 3

Community Service

19. I volunteer to assist with the unique needs of local families and the learning

1 2 3

community.

1 2 3

20. I volunteer to work with programs that seek to improve children’s academic skills.

Comments:

Total_____________

Teacher Education – ATE Application Package Revised: November 2016 LJ

Page8

www.gapsc.com

F.D. Toth, Executive Secretary

Georgia Professional Standards

Commission

Two Peachtree Street, Suite 6000

Atlanta, GA 30303-3141

Gary Walker, Director

Educator Ethics Division

404-232-2700

800-537-5996

Fax: 404-232-2720

ethica@gapsc.com

THE CODE OF ETHICS FOR EDUCATORS

Effective June 15, 2015

Introduction.

The Code of Ethics for Educators defines the professional behavior of educators in Georgia and serves as a guide to

ethical conduct. The

Professional Standards Commission has adopted standards that represent the conduct generally accepted by the

education profession. The code protects the health, safety and general welfare of students and educators, ensures

the citizens of Georgia a degree of accountability within the education profession, and defines unethical conduct

justifying disciplinary sanction.

Definitions

“Certificate” refers to any teaching, service, or leadership certificate, license, or permit issued by authority of the

Professional Standards Commission.

“Educator” is a teacher, school or school system administrator, or other education personnel who holds a

certificate issued by the Professional

Standards Commission and persons who have applied for but have not yet received a certificate. For the purposes

of the Code of Ethics for

Educators, “educator” also refers to paraprofessionals, aides, and substitute teachers.

“Student” is any individual enrolled in the state’s public or private schools from preschool through grade 12 or any

individual between and including the ages of 3 and 17.

“Complaint” is any written and signed statement from a local board, the state board, or one or more individual

residents of this state filed with the

Professional Standards Commission alleging that an educator has breached one or more of the standards in the

Code of Ethics for Educators. A “complaint” will be deemed a request to investigate.

“Revocation” is the invalidation of any certificate held by the educator.

“Denial” is the refusal to grant initial certification to an applicant for a certificate.

“Suspension” is the temporary invalidation of any certificate for a period of time specified by the Professional

Standards Commission.

“Reprimand” admonishes the certificate holder for his or her conduct. The reprimand cautions that further unethical

conduct will lead to a more severe action.

“Warning” warns the certificate holder that his or her conduct is unethical. The warning cautions that further

unethical conduct will lead to a more severe action.

“Monitoring“ is the quarterly appraisal of the educator’s conduct by the Professional Standards Commission through

contact with the educator and his or her employer. As a condition of monitoring, an educator may be required to

submit a criminal background check (GCIC). The

Commission specifies the length of the monitoring period.

STANDARDS

Standard 1: Legal Compliance - An educator shall abide by federal, state, and local laws and statutes. Unethical

conduct includes but is not limited to the Commission or conviction of a felony or of any crime involving moral

turpitude; of any other criminal offense involving the manufacture, distribution, trafficking, sale, or possession of a

controlled substance or marijuana as provided for in Chapter 13 of Title 16; or of any other sexual offense as

provided for in Code Section 16-6-1 through 16-6-17, 16-6-20, 16-6-22.2, or 16-12-100; or any other laws applicable to

the profession. As used herein, conviction includes a finding or verdict of guilty, or a plea of nolo contendere,

regardless of whether an appeal of the conviction has been sought; a situation where first offender treatment

without adjudication of guilt pursuant to the charge was granted; and a situation where an adjudication of guilt or

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Teacher Education – ATE Application Package Revised: November 2016 LJ

sentence was otherwise withheld or not entered on the charge or the charge was otherwise disposed of in a similar

manner in any jurisdiction.

Standard 2: Conduct with Students - An educator shall always maintain a professional relationship with all students,

both in and outside the classroom. Unethical conduct includes but is not limited to: 1. committing any act of child

abuse, including physical and verbal abuse; 2. committing any act of cruelty to children or any act of child

endangerment; 3. committing any sexual act with a student or soliciting such from a student; 4. engaging in or

permitting harassment of or misconduct toward a student that would violate a state or federal law; 5. soliciting,

encouraging, or consummating an inappropriate written, verbal, electronic, or physical relationship with a student;

6. furnishing tobacco, alcohol, or illegal/unauthorized drugs to any student; or 7. failing to prevent the use of

alcohol or illegal or unauthorized drugs by students who are under the educator’s supervision (including but not

limited to at the educator’s residence or any other private setting). (c)

Standard 3: Alcohol or Drugs - An educator shall refrain from the use of alcohol or illegal or unauthorized drugs

during the course of professional practice. Unethical conduct includes but is not limited to: 1. being on school or

Local Unit of Administration (LUA)/school district premises or at a school or a LUA/school district-related activity

while under the influence of, possessing, using, or consuming illegal or unauthorized drugs; and 2. being on school

or LUA/school district premises or at a school-related activity involving students while under the influence of,

possessing, or consuming alcohol. A school-related activity includes, but is not limited to, any activity sponsored by

the school or school system (booster clubs, parent-teacher organizations, or any activity designed to enhance the

school curriculum i.e. Foreign Language trips, etc). 505-6-.01 Page 3 (d)

Standard 4: Honesty - An educator shall exemplify honesty and integrity in the course of professional practice.

Unethical conduct includes but is not limited to, falsifying, misrepresenting or omitting: 1. professional qualifications,

criminal history, college or staff development credit and/or degrees, academic award, and employment history; 2.

information submitted to federal, state, local school districts and other governmental agencies; 3. information

regarding the evaluation of students and/or personnel; 4. reasons for absences or leaves; 5. information submitted

in the course of an official inquiry/investigation; and 6. information submitted in the course of professional practice.

Standard 5: Public Funds and Property - An educator entrusted with public funds and property shall honor that trust

with a high level of honesty, accuracy, and responsibility. Unethical conduct includes but is not limited to: 1.

misusing public or school-related funds; 2. failing to account for funds collected from students or parents; 3.

submitting fraudulent requests or documentation for reimbursement of expenses or for pay (including fraudulent or

purchased degrees, documents, or coursework); 4. co-mingling public or school-related funds with personal funds

or checking accounts; and 5. using school or school district property without the approval of the local board of

education/governing board or authorized designee.

Standard 6: Remunerative Conduct - An educator shall maintain integrity with students, colleagues, parents,

patrons, or businesses when accepting gifts, gratuities, favors, and additional compensation. Unethical conduct

includes but is not limited to: 1. soliciting students or parents of students, or school and/or LUA/school district

personnel, to purchase equipment, supplies, or services from the educator or to participate in activities that

financially benefit the educator unless approved by the local board of education/governing board or authorized

designee; 2. accepting gifts from vendors or potential vendors for personal use or gain where there may be the

appearance of a conflict of interest; 3. tutoring students assigned to the educator for remuneration unless

approved by the local board of education/governing board or authorized designee; and 4. coaching, instructing,

promoting athletic camps, summer leagues, etc. that involves students in an educator’s school system and from

whom the educator receives remuneration unless approved by the local board of education/governing board or

authorized designee. These types of activities must be in compliance with all rules and regulations of the Georgia

High School Association. 505-6-.01 Page 4 (g)

Standard 7: Confidential Information - An educator shall comply with state and federal laws and state school board

policies relating to the confidentiality of student and personnel records, standardized test material and other

information. Unethical conduct includes but is not limited to: 1. sharing of confidential information concerning

student academic and disciplinary records, health and medical information, family status and/or income, and

assessment/testing results unless disclosure is required or permitted by law; 2. sharing of confidential information

restricted by state or federal law; 3. violation of confidentiality agreements related to standardized testing including

copying or teaching identified test items, publishing or distributing test items or answers, discussing test items,

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Teacher Education – ATE Application Package Revised: November 2016 LJ

evised: November 2016 LJ

violating local school system or state directions for the use of tests or test items, etc.; and 4. violation of other

confidentiality agreements required by state or local policy. (h)

Standard 8: Abandonment of Contract - An educator shall fulfill all of the terms and obligations detailed in the

contract with the local board of education or education agency for the duration of the contract. Unethical

conduct includes but is not limited to: 1. abandoning the contract for professional services without prior release

from the contract by the employer, and 2. willfully refusing to perform the services required by a contract. (i)

Standard 9: Required Reports - An educator shall file reports of a breach of one or more of the standards in the

Code of Ethics for Educators, child abuse (O.C.G.A. §19-7-5), or any other required report. Unethical conduct

includes but is not limited to: 1. failure to report all requested information on documents required by the Commission

when applying for or renewing any certificate with the Commission; 2. failure to make a required report of a

violation of one or more standards of the Code of Ethics for educators of which they have personal knowledge as

soon as possible but no later than ninety (90) days from the date the educator became aware of an alleged

breach unless the law or local procedures require reporting sooner; and 3. failure to make a required report of any

violation of state or federal law soon as possible but no later than ninety (90) days from the date the educator

became aware of an alleged breach unless the law or local procedures require reporting sooner. These reports

include but are not limited to: murder, voluntary manslaughter, aggravated assault, aggravated battery,

kidnapping, any sexual offense, any sexual exploitation of a minor, any offense involving a controlled substance

and any abuse of a child if an educator has reasonable cause to believe that a child has been abused.

Standard 10: Professional Conduct - An educator shall demonstrate conduct that follows generally recognized

professional standards and preserves the dignity and integrity of the education profession. Unethical conduct

includes but is not limited to any conduct that impairs and/or diminishes the certificate holder’s ability to function

professionally in his or her employment position, or behavior or conduct that is detrimental to the health, welfare,

discipline, or morals of students.

Standard 11: Testing – An educator shall administer state-mandated assessments fairly and ethically. Unethical

conduct includes but is not limited to: 505-6-.01 Page 5 1. committing any act that breaches Test Security; and 2.

compromising the integrity of the assessment. (4) Reporting (a) Educators are required to report a breach of one or

more of the Standards in the Code of Ethics for Educators as soon as possible but no later than ninety (90) days from

the date the educator became aware of an alleged breach unless the law or local procedures require reporting

sooner. Educators should be aware of legal requirements and local policies and procedures for reporting unethical

conduct. Complaints filed with the Georgia Professional Standards Commission must be in writing and must be

signed by the complainant (parent, educator, or other LUA/school district employee, etc.). (b) The Commission

notifies local and state officials of all disciplinary actions. In addition, suspensions and revocations are reported to

national officials, including the NASDTEC Clearinghouse. (5) Disciplinary Action (a) The Georgia Professional

Standards Commission is authorized to suspend, revoke, or deny certificates, to issue a reprimand or warning, or to

monitor the educator’s conduct and performance after an investigation is held and notice and opportunity for a

hearing are provided to the certificate holder. Any of the following grounds shall be considered cause for

disciplinary action against the holder of a certificate: 1. unethical conduct as outlined in The Code of Ethics for

Educators, Standards 1-11 (GaPSC Rule 505-6-.01); 2. disciplinary action against a certificate in another state on

grounds consistent with those specified in the Code of Ethics for Educators, Standards 1-11 (GaPSC Rule 505-6-.01);

3. order from a court of competent jurisdiction or a request from the Department of Human Resources that the

certificate should be suspended or the application for certification should be denied for non-payment of child

support (O.C.G.A. §19-6-28.1 and §19-11-9.3); 4. notification from the Georgia Higher Education Assistance

Corporation that the educator is in default and not in satisfactory repayment status on a student loan guaranteed

by the Georgia Higher Education Assistance Corporation (O.C.G.A. §20-3-295); 5. suspension or revocation of any

professional license or certificate; 6. violation of any other laws and rules applicable to the profession; and 7. any

other good and sufficient cause that renders an educator unfit for employment as an educator. (b) An individual

whose certificate has been revoked, denied, or suspended may not serve as a volunteer or be employed as an

educator, paraprofessional, aide, substitute teacher or in any other position during the period of his or her

revocation, suspension or denial for a violation of The Code of Ethics. The superintendent and the educator

designated by the superintendent/Local Board of Education shall be responsible for assuring that an individual

whose certificate has been revoked, denied, or 505-6-.01 Page 6 suspended is not employed or serving in any

capacity in their district. Both the superintendent and the superintendent’s designee must hold GaPSC certification.

Should the superintendent’s certificate be revoked, suspended, or denied, the Board of Education shall be

responsible for assuring that the superintendent whose certificate has been revoked, suspended, or denied is not

employed or serving in any capacity in their district. Authority O.C.G.A. § 20-2-200; 20-2-981 through 20-2-984.5A

I have read and understand the Code of Ethics for Educators.

Teacher Education – ATE Application Package R

Page11

Signature: _______________________________________ Date: ______________

Letter of Recommendation Form

Educator Preparation Program

Applicant:

Date:

SUMMARY EVALUATION

Unacceptable

Below Average

Acceptable

Average

Targeted

Above

Average

Top

10%

Inadequate

Opportunity

To Observe

Research aptitude

Intellectual ability

Ability to work with others

Creativity and

imagination

Maturity

Self-confidence

Communication skills-oral

Communication skills-

written

Analytic ability

Motivation

Potential in career field

Comment Box:

Signature: ________________________________ Date: .

Teacher Education – ATE Application Package Revised: November 2016 LJ

Page12

Letter of Recommendation Form

Educator Preparation Program

Applicant:

Date:

SUMMARY EVALUATION

Unacceptable

Below Average

Accepta

ble

Average

Targeted

Above

Average

Top

10%

Inadequate

Opportunity

To Observe

Research aptitude

Intellectual ability

Ability to work with others

Creativity and

imagination

Maturity

Self-confidence

Communication skills-oral

Communication skills-

written

Analytic ability

Motivation

Potential in career field

Comment Box:

Signature: _____________________________________ Date:___________________

Teacher Education – ATE Application Package Revised: November 2016 LJ

Page13

Essay Analysis and Critique Rubric

Educator Preparation Program

Two-page minimum

Name: ___________________________________________________________________ RAM ID: ____________________________

Essay Topic: How will I use my content knowledge, technological skills, and cultural awareness to influence and

transform the students that I work with while maintaining Ethical Standards when I become a Educator?

Applicant’s Checklist

12 point size

Concluding paragraph

Times New Roman font

Minimum 3-paragragh body

Typed, double spaced

Introductory paragraph

Scoring Key

Appraisal

Remarks

I.

Content

3 = Well organized and developed content, good use and interpretation of

professional code of ethics, good focus of how writer wants to impact students as

an educator, understands philosophy of education concepts. Demonstrates

awareness of Cultural impacts on Learning and Teaching.

2 = Some organization to content, little interpretation of professional code of ethics,

questionable focus on why writer wants to become educator, questionable

understanding of philosophy of education concept. Little understanding of the

Impact of Cultural systems on Learning and Teaching.

1 = Little organization, little interpretation of professional code of ethics, little focus

on why writer wants to become educator, no understanding of philosophy of

education concepts. No Understanding of Cultural impacts on Learning and

Teaching.

II.

Style

3 = Fluid, easy to read, excellent use of word, descriptive, concise follows assigned

task.

2 = Easy to read but lacking in descriptive quality, some rambling, some misuse of

words, drifts from assigned task.

1 = difficult to follow, extensive rambling, little description, directions not followed.

III.

Mechanics

3 = Targeted: Excellent command of grammar & mechanics; few, if any

Errors.

2 = Acceptable : Good command of grammar & mechanics; some errors

but does not impede comprehension of content

1 = Unacceptable: Poor command of grammar & mechanics;

numerous errors

ADD Sections I thru III

MULTIPLY score x 11

(Minimal Passing Score = 77) Total Evaluation Score

Page14

Teacher Education – ATE Application Package Revised: November 2016 LJ

______________________________________ __________________________

Educator Preparation Program

Professional Dispositions Statement

Candidates in the Educator Preparation Program at Albany State University are expected to

demonstrate professional dispositions at the acceptable level. These dispositions will be evaluated by

university professors during classes and university supervisors/cooperating stakeholders during field and

clinical experiences. Failure to do so may result in dismissal from the course, field/clinical experience.

Continued failure to demonstrate professional dispositions may result in dismissal from the Education

Program.

 The candidate demonstrates an understanding of the curriculum, subject content, and

pedagogical knowledge for the discipline.

 The candidate plans appropriately for class, field/clinical experiences and professional

development opportunities.

 The candidate models research based clinical/instructional strategies relevant to the content

area and self-engages in active learning that promotes development of key skills.

 The candidate engages in activities and conversations that show an appreciation for individual

learning differences.

 The candidate uses reflection, constructive criticism and self-assessment to transform current skills

and dispositions for self and others.

 The candidate systematically gathers, analyzes, and uses relevant data to measure self-

progress, to inform clinical/instructional participation, and to engage in relevant conversations

with educational leaders about academic success.

 The candidate displays dispositions that contribute to a safe, orderly environment that is

conducive to learning and encourages respect for all.

 The candidate contributes to the academic environment in a manner that facilitates teaching

and learning at high levels.

 The candidate demonstrates a commitment to professional ethics and dispositions, including

dress, attendance, honesty, confidentiality and criminal offenses.

 The candidate communicates effectively with University faculty/staff, other candidates, P-12

students, parents or guardians, district and school personnel, and other stakeholders in ways that

enhance learning.

My signature below indicates that I have read and understand the disposition policy and I agree

to abide by the standards stated while enrolled in the Educator Preparation Program at Albany

State University.

Candidate Signature Date

Teacher Education – ATE Application Package Revised: November 2016 LJ

Page15

1.

7.

5.

6.

GaPSC Pre-Service Certificate Application

Please Use Black Ink or Type – Revised April 2015

This form must be submitted by an educator preparation provider. Candidates should not submit this form directly to the GaPSC.

1. Please use ALL CAPS to print your LEGAL NAME.

Last Name

First Name Middle Name

Social Security Number Date of Birth (MM/DD/YY) Telephone Number

-

/

-

Mailing Address

City State Zip Code

-

Gender (check one) Ethnicity (check one)

Male Female Are you Hispanic or Latino of any race? Yes No

Race (check all that apply)

Asian

American Indian or Alaska

Black or African

Native Hawaiian or Pacific

White

Native

American

Islander

2. Personal Affirmation: The applicant should enter a truthful "Yes" or "No" response to each of the following questions.

All questions must have a response in order for the application process to continue. "YES" responses automatically

open an investigation and require an attached explanation along with any additional supporting documentation.

DO

NOT include matters that the GaPSC has investigated or is currently investigating.

Y N

Consent:

Y N

Have you ever had an adverse action (i.e. warning, reprimand, suspension, revocation, denial, voluntary

surrender, disbarment) taken against a professional certificate, license or permit issued by an agency OTHER

THAN the Georgia Professional Standards Commission?

Y N

2. Are you currently the subject of an investigation involving a violation of a profession’s laws, rules, standards or

Code of Ethics by an agency OTHER THAN the Georgia Professional Standards Commission?

Y N

3. Have you ever received a less than honorable discharge from any branch of the armed services? (If “yes”, provide

a copy of form DD214.)

Y N

4. While under investigation, have you ever

terminated, non-renewed or otherwise)?

left an employment position (retired, resigned, been dismissed,

Are you currently the subject of an investigation involving sexual misconduct or physical harm to a child?

Are you the subject of a pending investigation involving a criminal act?

For any felony or any crime involving moral turpitude, have you ever:

♦ Pled guilty;

♦ Entered a plea of nolo contendere;

♦ Been found guilty;

♦ Pled guilty to a lesser offense;

♦ Participated in a pre-trial diversion program;

♦ Been granted first offender treatment without

adjudication of guilt;

♦ Been found not guilty by reason of insanity; or

♦ Been placed under a court order whereby an

adjudication or sentence was withheld?

Y N

8. Have you ever been convicted, or pled to a lesser offense for any sexual offense?

Y N

9. Have you been convicted of a drug offense (felony or misdemeanor)?

I hereby authorize the Georgia Professional Standards Commission to receive any criminal history record

information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia, and to

perform periodic criminal history background checks for the duration of my certification in the state of Georgia.

Signature: ______________________________________________________ Date: ______________________________

NOTE: This application must be received by the GaPSC within 90 days of the date of signature.

INSTRUCTIONS FOR COMPLETING VERIFICATION OF LAWFUL PRESENCE AFFIDAVIT

In order to obtain a certificate/license from the Georgia Professional Standards Commission (GaPSC), Georgia

law requires every applicant to complete an affidavit (sworn written statement) before a Notary Public that

establishes that the applicant is lawfully present in the United States of America. This affidavit is a material part of

your GaPSC certification/licensure application and must be completed truthfully. Your application may be denied

or your certificate may be revoked by the GaPSC if it is determined that you have made a material misstatement

of fact in connection with your application. Please follow the instructions listed below.

You must submit the following with your Pre-Service Application and GCIC Consent Form:

1. Notarized Affidavit (page 3 of this document)

2. A copy of an acceptable ID (see below)

1. Select the ONE option on the affidavit that applies to you:

 Option 1 is to be initialed/selected by you if you are a United States citizen; or

 Option 2 is to be initialed/selected by you if you are a legal permanent resident of the United States: you

are not a U.S. citizen but you have a green card; or

 Option 3 is to be initialed/selected by you if you are a qualified alien or non-immigrant (but not a U.S.

citizen or a legal permanent resident).

If you selected Option 2 or 3, please provide the number (whether or not it is called an “alien number”)

issued by the Department of Homeland Security or other federal immigration agency in the blank space

following this statement: “My alien number issued by the Department of Homeland Security or other federal

immigration agency is:”

2. Select an acceptable ID based on your selection in Step 1.

 Acceptable IDs for Option 1 (U.S. citizen) are:

o An unexpired driver’s license issued by a U.S. state, D.C., or certain U.S. territories

o An unexpired United States passport or passport card

o An unexpired United States military identification card

o Any document listed here:

http://www.gapsc.com/certification/downloads/SecureVerifiableDocuments.pdf

 The only acceptable ID for Option 2 (legal permanent resident) is a copy of the front and back of your

unexpired United States Permanent Resident Card.

 Acceptable IDs for Option 3 (qualified alien or non-immigrant) are:

o An unexpired work authorization card

o I-94 documentation reflecting the I-94 number and expiration date AND a valid foreign passport

o A valid Certificate of Eligibility reflecting your SEVIS number AND a valid foreign passport

Fill in the type of ID (e.g. Georgia driver’s license, U.S. passport, etc.) that you are using on the affidavit on

the line after “The secure and verifiable document provided with this affidavit can best be classified as:”

3. Print out the affidavit (page 4 of this document).

4. Find a local Notary Public. Check the yellow pages, the internet, or with a local business such as a bank.

5. Bring your affidavit and the ID you selected (from the list in Step 2) to appear before the Notary Public.

6. Show the Notary Public your ID and state under oath in the presence of the Notary Public that you are

who you say you are and that you are in the United States lawfully. Then sign your name.

7. Make certain that the Notary Public signs and dates the affidavit and lists when their notary

commission expires.

8. Make a copy of the affidavit and the ID that you presented to the Notary Public for your own records.

9. Submit the following with your Pre-Service Application and GCIC Consent Form:

 A copy of the signed and notarized affidavit; and

 A copy of the ID you presented to the Notary Public.

____________________________________

_________________________

O.C.G.A. § 50-36-1(e)(2) Affidavit

By executing this affidavit under oath, as an applicant for a Georgia Educator Certificate/License, as

referenced in O.C.G.A. § 50-36-1, from the Georgia Professional Standards Commission, the undersigned

applicant verifies one of the following with respect to application for a public benefit:

1) _________ I am a United States citizen.

2) _________ I am a legal permanent resident of the United States.

3) _________ I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act

with an alien number issued by the Department of Homeland Security or other federal

immigration agency.

My alien number issued by the Department of Homeland Security or other federal

immigration agency is: ____________________.

The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has provided at

least one secure and verifiable document, as required by O.C.G.A. § 50-36-1(e)(1), with this affidavit.

The secure and verifiable document provided with this affidavit can best be classified as:

_______________________________________________________________________.

In making the above representation under oath, I understand that any person who knowingly and willfully

makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation

of O.C.G.A. § 16-10-20, and face criminal penalties as allowed by such criminal statute.

Executed in ___________________ (city), __________________(state).

Signature of Applicant

Printed Name of Applicant

SUBSCRIBED AND SWORN

BEFORE ME ON THIS THE

___ DAY OF ___________, 20____

NOTARY PUBLIC

My Commission Expires:

Albany State University Police Department/College of Education

Consent Form

Semester/Year: _________________ Home Campus: ASU Cairo Waycross (Circle One)

Purpose of Criminal Background Check:

Program: ______________________________ Ex. Early Childhood _____ Admission to Teacher Education

Concentration(s): ________________________ (Middle Grades & SPED only) _____ Field Experiences

_____ Practicum I, II, or III

Education Classes: ____________________________________________ _____ Clinical Experiences/Student Teaching

Leadership Classes: ___________________________________________ _____ Leadership Residency

Counseling Classes: ___________________________________________ _____ Counseling Practicum

I,______________________ hearby authorize Albany State University to receive any Georgia crimininal record

pertaining to me which may be in the files of any state or local criminal justice agency in Georgia.

Please type or print the following information: (ALL FIELDS MUST BE COMPLETED).

Last Name Middle Name First Name Maiden Name

Address City State Zip Code

Phone # Sex/Race Date of Birth Social Security

For Security Department Use Only

Arrest record on file? (If record, see attached) _____________________________________________

Record of any convictions? (If record, see attached)_____________________________________________

Signature, ASU Police Representative ______________________________ Date _____________________

_______________________________________________________________

Albany State University Police Department/College of Education

AUTHORIZATION FOR RELEASE OF INFORMATION

Please print clearly all requested information.

First Name___________________ Middle Name_______________ Last Name__________________________

Date of Birth_________________ SSN______________________ Ram ID_____________________________

Address___________________________________________________________________________________

Major_________________________________ Classification ________________________________________

City______________________________________ State_________ Zip Code___________________________

Home Telephone Number__________________________ Cell Number _______________________________

I hereby authorize your company, Albany State University, or any agent of said company, to contact any of my

previous employers or contact schools, companies, credit bureaus, corporations, law enforcement agencies,

persons, and educational institutions to supply any information concerning my background.

I hereby also give my permission for the release of all appropriate background information permissible by

governing laws to the College of Education and Local Education Agencies (LEAs) to which I may be assigned

to conduct field and/or clinical experiences.

This authorization is valid 90/180 days from the date of signature. I fully understand the terms of this release

and attest that the information I have provided is accurate, true and correct.

Executed this ______________day of______________________________, 20______

(Date) (Month) (Year)

(City) (State)

Candidate (Student) Signature ____________________________________

Notary Public Signature __________________________________________

My Commission Expires: _________________________________________

Albany State University agrees that neither NCIC, GCIC its employees nor any other agency or employees of the state

of Georgia shall be responsible for the accuracy of information or have any liability for defamation, invasion of privacy,

negligence or any other claim in connection with any dissemination of information pursuant to this record check.

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