College of Education
T E X A S A&M I N T E R N A T I O N A L U N I V E R S I T Y
A Member of The Texas A&M University System
COLLEGE OF EDUCATION
FIELD PLACEMENT APPLICATION- BLOCK III (Clinical Teaching)
SEMESTER APPLYING FOR:
Name: Student ID #:
Address:
(Street No. / P.O. Box) (City) (State) (Zip Code)
Contact Phone Number:
(Home) (Work) (Cell Phone #)
TAMIU Email Address: Major: _________________Area of Certification:_________________
Provide the following information: (To be used for Public School Placement purposes)
Do you currently have a family member working in a school district?
Yes ______ No _______
Name of family member (s) _________________________,___________________________,_____________________________
Campus where they work ___________________________,______________________________,__________________________
_____Do you
currently hold FULL TIME employment as a TEACHER ASSISTANT or PARAPROFESSIONAL in a school district?
If YES, Name of Employing School District & Campus.______________
_________________ Position Held: _________________
_____________
______________________________________________________________________________________________
*Based on the Educator Preparation Program procedures and policies, in accordance with the State Board of Educator Certification, it is
necessary for individuals to have a valid Social Security number and a valid Driver’s License number (or other state-issued identification
card) in order to complete program requirements for field/clinical placements. Placement in the school setting is contingent upon a
criminal background check.
5201 U
niversity Boulevard, Laredo, Texas 78041-1900. (956) 326-2435, Fax (956) 326-2424
AREA OF SPECIALIZATION:
Degree:______________________(BA/BS) Major:___________________ Area of Certification: ________________________________
B
lock IA School: _________________________________________ Grade Level/Subject: ___________________________________
Block IB School: ______________________ ___________________ Grade Level/Subject: ___________________________________
Block IAB School: ________________________________________ Grade Level/Subject: ___________________________________
Block II School:___________________________________________ Grade Level/Subject: ___________________________________
___________________________________________________________________________________________________________________________
1. Will you be taking a class(es) during Clinical Teaching?__________________________
If the answer is yes, please list those course(s) which you plan to take along with Student Teaching:
*** ____________________________________________________________________________________________________
*** KEEP IN MIND THAT ANY CLASS (ES) TAKEN WITH THE INTERNSHIP NEED TO BE APPROVED BY
THE DIRECTOR OF FIELD AND CLINICAL EXPERIENCES.
DPS Computerized Criminal History (CCH) Verification
(AGENCY COPY)
I, , acknowledge that a Computerized Criminal
APPLICANT or EMPLOYEE NAME (Please print)
History (CCH) check will be performed by accessing the Texas Department of Public Safety Secure
Website and will be based on name and DOB identifiers I supply. (This is not a consent form.) Authority
for this agency to access an individual’s criminal history data may be found in Texas Government Code
411; Subchapter F.
Name-based information is not an exact search and only fingerprint record searches represent
true identification to criminal history, therefore the organization conducting the criminal history check is
not allowed to discuss with me any criminal history record information obtained using this method. The
agency may request that I have a fingerprint search performed to clear any misidentification based on
the result of the name and DOB search. Once this process is completed the information on my
fingerprint criminal history record may be discussed with me.
In order to complete the process I must make an appointment with the Fingerprint Applicant
Services of Texas (FAST) as instructed online at www.txdps.state.tx.us /Crime Records/Review of
Personal Criminal History or by calling the DPS Program Vendor at 1-888-467-2080, submit a full and
complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $24.95 to
the fingerprinting services company.
(This copy must remain on file by your agency. Required for future DPS Audits)
___________________________________
Signature of Applicant or Employee
Date
Laredo ISD
Agency Name (Please print)
Diana R. Martinez
Agency Representative Name (Please print)
___________________________________
Signature of Agency Representative
Date
Rev. 09/2013
Please:
Check and Initial each Applicable Space
CCH Report Printed:
YES
NO
initial
Empl
Vol/Contractor
initial
Date Printed:
/
initial
Destroyed Date:
initial
Retain in your files
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Pre-Employment Affidavit for Applicant
For purposes of this affidavit:
Adjudication and conviction refer to a conviction, plea of guilty or no contest (nolo
contendre), probation, suspension, or deferred adjudication.
Charge refers to a formal criminal charge as documented by a primary charging instrument
(a complaint, information, or indictment) under the Texas Code of Criminal Procedure.
Inappropriate relationship refers to the crime of improper relationship between educator
and student in Texas Penal Code section 21.12, and any other inappropriate relationship as
determined by the State Board for Educator Certification.
I declare the following:
o I have never been charged with, adjudicated for, or convicted of having an inappropriate
relationship with a minor.
o I have been charged with, adjudicated for, or convicted of having an inappropriate
relationship with a minor. The charge, adjudication, or conviction was determined to be
false. The following are all of the relevant facts pertaining to the charge, adjudication, or
conviction:
o I have been charged with, adjudicated for, or convicted of having an inappropriate
relationship with a minor. The charge, adjudication, or conviction was determined to be
true. The following are all of the relevant facts pertaining to the charge, adjudication, or
conviction:
------------------------------------------------------------------------------------------------------------------------------
Declaration of Applicant
The following affidavit is offered to satisfy the requirement of Texas Education Code section 21.009
for a pre-employment affidavit, in accordance with Texas Civil Practices and Remedies Code section
132.001. An applicant who is offered employment will be asked to complete a notarized affidavit
attesting to the same.
I declare under penalty of perjury that the foregoing is true and correct.
_______________________________________________________________________
Name
(First, Middle, Last)
__________________________________
Date of Birth
___
____________________________________________________________________
Address
(Street, City, State, Zip Code)
__________________________________
County
Executed in ____________________ County, State of Texas, on the _____ day of ____________________, __________.
County Date Month Year
I understand that the date of birth I am providing will not be used to determine eligibility for
employment but will be used solely for the purpose of this pre-employment affidavit.
*
*
This form will be removed from the application and filed separately in the HR office.
_____________________________________________________________________
(Signature of Declarant)
Approved by the Texas Commissioner of Education, October 2017.
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Please:
Check and Initial each Applicable Space
CCH Report Printed:
YES NO
initial
Purpose of CCH:
Empl Vol/Contractor
initial
Date Printed:
initial
Destroyed Date:
initial
Retain in your files
DPS Computerized Criminal History (CCH) Verification
(AGENCY COPY)
I, , acknowledge that a Computerized Criminal
APPLICANT or EMPLOYEE NAME (Please print)
History (CCH) check will be performed by accessing the Texas Department of Public Safety Secure
Website and will be based on name and DOB identifiers I supply. (This is not a consent form.) Authority
for this agency to access an individual’s criminal history data may be found in Texas Government Code
411; Subchapter F.
Name-based information is not an exact search and only fingerprint record searches represent
true identification to criminal history, therefore the organization conducting the criminal history check is
not allowed to discuss with me any criminal history record information obtained using this method. The
agency may request that I have a fingerprint search performed to clear any misidentification based on
the result of the name and DOB search. Once this process is completed the information on my
fingerprint criminal history record may be discussed with me.
In order to complete the process I must make an appointment with the Fingerprint Applicant
Services of Texas (FAST) as instructed online at www.txdps.state.tx.us /Crime Records/Review of
Personal Criminal History or by calling the DPS Program Vendor at 1-888-467-2080, submit a full and
complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $24.95 to
the fingerprinting services company.
(This copy must remain on file by your agency. Required for future DPS Audits)
Signature of Applicant or Employee
Date
United Independent School District
Agency Name (Please print)
Agency Representative Name (Please print)
Signature of Agency Representative
Date
Rev. 09/2013
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UNITED INDEPENDENT SCHOOL
DISTRICT
Human Resources Department
201 Lindenwood Dr., Laredo, Texas 78045 (956) 473-6273; (956) 473-6303
Fax
CRIMINAL HISTORY RECORD
INFORMATION AUTHORIZATION FOR
STUDENT TEACHERS AND VOLUNTEERS
The United Independent School District is required by the Texas Education Code Chapter 22, Subchapter C to review the criminal
history of applicants, employees, independent contractors, student teachers and volunteers. The information requested below is
necessary to obtain criminal history.
I authorize the United Independent School District to obtain copies of any information pertaining to any criminal history
rec
ord
maintained by any law enforcement agency and to use said information for the purpose of evaluating my application for
volunteering.
In order to obtain a criminal check you must be 18 years or older
PERSONAL
INFOR
M
A
T
I
O
N
Legal
Name:
Date
of
Birth:
/
/
First Name Middle Last Month/Day/Year
Address:
City:
State:
Zip
Code:
Sex:
Male/Female
Driver’s
License
Number/State
Issued:
Moral turpitude is an act of baseness, vileness or depravity in the private or social duties outside the accepted standards
o
f decency
and that shocks the conscience of an ordinary person, including, but not limited to theft, murder, rape, swindling and
indece
ncy with
a minor.
Yes No Have you ever been arrested?
*An arrest is not an automatic bar to volunteering. The district will consider the nature and date of the offense,
and the relationship between the offense and the volunteer position for which you are applying.
If yes, pl
ease attach a statement of the nature of the offense.
Yes No Have you ever been convicted of, pled guilty or no contest (nolo contendere) to, or received probation,
suspension, or deferred adjudication for a felony or any offense involving moral turpitude (including, but not
limited to theft, rape, murder, swindling, and indecency with a minor)?
If yes, please attach a statement of the nature of the offense.
Yes No Have you ever been charged with, been convicted of, received deferred adjudication (probation), pled guilty or
nolo contendere for an offense or capital murder, attempted murder, murder, voluntary manslaughter,
involuntary manslaughter, indecency with a child, injury to a child or elderly or disabled individual, kidnapping,
deadly weapon was used or exhibited or for any felony related to the manufacture, delivery or possession of
marijuana, a controlled substance, or dangerous drug?Conviction” shall include probation or deferred
adjud
ication (probation), a finding of guilt or acceptance by the court of a plea of guilty, or nolo
contender
e review
each application according to the criteria set forth in the district’s DC (Local) policy.
Volunteer/Student
Teacher
Signature:
Date:
Parent’s
Signature:
Date:
(Required if intern is under 18 yrs. of age or a current U.I.S.D. student)
Sec. 22.0835. Access to Criminal History Records of Student Teachers and Volunteers by Local and Regional Education Authorities.
(a) A School district, open-enrollment charter school, or shared services arrangement shall obtain from the department and may obtain from any other law
enforcement or criminal justice agency or a private entity that is a consumer reporting agency governed by the Fair Credit Reporting Act (15 U.S.C. Section
1681 et seq.), all criminal history record information that relates to: (1) a person participating in an internship consisting of student teaching to receive a
teaching certificate; or (2) a volunteer or person who has indicated, in writing, an intention to serve as a volunteer with the district, school, or shared
services arrangement. (c) A person to whom Subsection (a) or (b) applies must provide to the school district, open-enrollment charter school, private
school, regional education service center, or shared services arrangement a driver’s license or another form of identification containing the person’s
photograph issued by an entity of the United States government.
UISD Form 903-050,
04-2019
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Observation Screening Requirements
The United Independent School District welcomes partnerships with local and nearby institutes of higher
learning. In order to provide the safest environment for the Districts students and staff, any student intern
requesting an opportunity to conduct classroom observations as part of a coursework requirement will
need to meet the screening requirements listed below:
Category A
Education interns who are enrolled in Block I, II or III at Texas A&M International University
Provide evidence of current enrollment at TAMIU (N/A if Observation Request is submitted by
College of Education)
Submit Criminal History Waiver and meet the conditions of a criminal background check
Present a Tuberculosis clearance card (TB test must be administered within 120 days of request)
Category B
Alternative Certification Program (ACP) Candidates
Provide evidence of current acceptance to an ACP program
Submit Criminal History Waiver and meet the conditions of a criminal background check
Present a Tuberculosis clearance card (TB test must be administered within 120 days of request)
Category C
Student interns who are required to conduct classroom observations as part of their University or College
coursework
Provide evidence of current enrollment at a College or University (Ex: Copy of school ID)
Provide evidence from College or University Professor noting requirement/permission to conduct
observation hours in a classroom setting (must be signed and on official letterhead)
Submit Criminal History Waiver and meet the conditions of a criminal background check
Present a Tuberculosis clearance card (TB test must be administered within 120 days of request)
!
The!release!of!a!clearance!form!is!in!no!w ay!an!offer!of!employment.!!Moreover,!while!the!District!m ay!allow!you!to!
observe!in!the!classroom,!the!District!does!not!herby!admit!that!you!are!entitled!or!qualified!for!an!employment!
position.!!Interns!are!required!to!abide!by!the!District’s!Standards!of!Dress!as!outlined!by!Policy!DH!(Local.)!!
Date of Request: _________________ Category (circle one): A B C
Name: _______________________________________________________________
Home Phone: _________________ Mobile Phone: ________________ Email: ________________
Are you a current or former employee of UISD: _________________________
Number of Observation Hours Requested: ____________________________
Current Student
Name of College / University: _________________________________
(Attach copy of current school ID)
Alternative Certification Candidate
Name of ACP program: _____________________________________
(Attach copy of Program Acceptance Letter)
Please allow 7 working days for observation requests to be processed.