Dear Cooperating Teacher:
Please supply the following information for the teacher candidate placement listed below.
Cooperating Teacher: __________________________________ Grade level/subject: ____________________________
Home Address: ______________________________________________ Room Number: _________________________
_______________________________________________ e-mail: ___________________________________________
Home Phone: _______________________________ listed: _______ unlisted: _______ unpublished: _______
Cooperating School: ______________________________________ District: ___________________________________
School Address: ___________________________________________________________________________________
School Phone: ___________________________________________________
Principal: __________________________________ Principal e-mail: _________________________________________
Teacher Candidate: ________________________________________________School Term: ___________________
Address (during teacher candidacy): _________________________________________________________________
______________________________________________________ Phone: __________________________________
Please check the ones that apply:
1. _____ Wisconsin Teaching Certification: (grade level(s) and subject(s)) ______________________________________
_____________________________________________ __________________________________________
2. _____ At least 3 years teaching experience (yr) __________ to (yr) ___________ (yrs of experience)
3. _____ At least 1 year in the current school system ______________ (year began in current district)
4. _____ Have taken supervision course [P134.15(6)] Institution/Sem/Yr. ______________________________________
_____ Currently enrolled in a supervisor course or seminar to be completed prior to the teacher candidate beginning
the experience. Institution: ___________________________________________ Date: ___________________
5. _____ Approved by principal and/or district administrator to serve in this capacity.
The above information concerning the cooperating teacher requirements is accurate to the best of my knowledge.
__________________________________________________________ ____________________
(signature of cooperating teacher) (date)
Please attach a copy of the schedule of the school day and a school calendar and mail in the enclosed envelope. Thank you.
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