EDUCATOR PREPARATION INSTITUTE
Student Data Form
(Please Print)
Date
Last Name: First Name: Middle Initial:
IRSC Student ID: Date of Birth:
Address: Apartment #:
City: State: Zip:
Home phone #: Work #: Cell #:
Email:
1) What is your degree area? Bachelor’s
Master’s
Doctorate
2) What grade level do you plan to teach or are presently teaching?
ECE (P-3) Elementary (K-6) Middle School (5-9) Subject Area
High School (6-12) Subject Area
Name of School (if presently teaching)
3) How did you hear about the Educator Preparation Institute?
Another student Teacher Advisor Presentation News article
Poster Brochure Web site Other:
5) Did you complete an application to the Florida Department of Education for a
Temporary Certificate? Yes No
6) Do you have a statement of your Status of Eligibility?
Yes
No
7) In which county are you planning to teach?
8) Which FTCE exams have you passed?
Subject Area in your area of certification
General Knowledge (math, reading, language arts, writing)
Professional Education
I understand that when I complete my field experience for each class it must be done in a
classroom where 1) the teacher is certified in the same subject area in which I am seeking
certification and 2) the subject being taught and grade level match the subject and grade level on
my statement of eligibility. I understand that each field experience must be completed in a
different classroom/school.
Signature Date
Updated 10-2016
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signature
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