(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.)
The School of E ducation requires app licants for admission t o programs leading to a certificate or license t o teach, or requiring
field placement, e .g. field experience, elementary and /or secondary methods, human relations practicum, or teacher 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 Department 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 complete t he Disc
losure Questionnaire, falsification or omission o f information relevant t o these questions constitutes the
l 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
ogram, to postpone admission, or to place special conditions on admission or to provide special accommodations.
the event a student
i s denied admission to the program based on responses to the questions below, the student has the right to
appeal t
hat 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.
Name __________________________________________ Student ID _______________________________________
(First) (M.I.) (Last)
SS # __________________________________________
Previous Name (If Any) ____________________________
Birth date ________________________________________
Alias/Maiden ____________________________________
Ethnicity _________________________________________
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 experien
ce or
teacher c
andidacy placement, or denial or revocation of certification. I also hereby authorize WLC t o conduct t he necessary
background check.
_______________________________________________ _________________________________________
Student Signature Date
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
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Name ______________________________________SSN__________________________Date ___________________
Attach additional pages as necessary to fully respond to questions below.
1. Have you ever had a teaching license?
Has teac
hing 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 disciplined by any col
lege or university or from any program of a
ge or university, either for academic or othe
r reasons? If “Yes,please describe
Yes No
3. Have you ever been terminated for cause from an employment situation? If “Yes,” please
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 standards?
Yes No
6. Have you ever been investigated for any conduct listed in Questions 4 and 5 above?
Yes No
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 f ield experience or practicum,
teacher candidacy, or internship with or without reasonable accommodation?
If “Yes, with accommodat
ion” is checked, please describe with what reasonable conditions or
circumstances you are able t o c arry out the duties and r esponsibilities of the pos ition w hich
you seek:
(Note: Wisconsin Lutheran College makes reasonable accommodations.)
Yes w/ accomm
Yes w/o accomm
A CRI MINAL HI STORY BA CKGROUND CH ECK b ased o n i nformation o n t his form w as p erformed through t he WISCONSIN
DATE: _________________ Order Number: _____________ RESULTS: ___________________________________
CHECK PERFORMED BY: _____________________________ - Wisconsin Lutheran College - School of Education
8800 West Bluemound Road
Milwaukee, Wisconsin 53226
WLC School of Education Director
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