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InformationFormOld UNIVERSITY OF EVANSVILLE

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1
UNIVERSITY OF EVANSVILLE
SCHOOL OF EDUCATION
STUDENT TEACHING
Information Form
PLEASE TYPE INFORMATION
The information requested will be of value to your supervising teacher in guiding you during
your student teaching activities. Please answer each question as completely as possible.
Date of application ___________ Semester/Year that student teaching is planned____________
PERSONAL DATA
Name __________________________________________ Date of Birth _________________
(Last) (First) (Middle)
Permanent Address_________________________________________Phone (____) _________
University Address_________________________________________Phone (____) _________
EDUCATION BACKGROUND
High School(s) Attended:
Name Location
________________________________ ___________________________________________
________________________________ ___________________________________________
________________________________ ___________________________________________
Year graduated___________________ Rank/Size of Class ____________________
List high school organizations and activities in which you participated:
_________________________ _______________________ ________________________
_________________________ _______________________ ________________________
List leadership positions held in high school organizations:
_________________________ _______________________ ________________________
List special honors you received in high school:
_________________________ _______________________ ________________________
What high school subjects did you consider least difficult:
_________________________ _______________________ ________________________
What high school subjects did you consider most difficult:
_________________________ _______________________ ________________________
College(s) Attended:
Name Hours Earned Dates
____________________________ ___________ _____________________
____________________________ ___________ _____________________
____________________________ ___________ _____________________
List collegiate organizations and activities in which you participated:
_________________________ _______________________ ________________________
_________________________ _______________________ ________________________
List leadership positions held in college organizations:
_________________________ _______________________ ________________________
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2
List special honors you received in college:
_________________________ _______________________ ________________________
What courses have you especially enjoyed or profited from at the collegiate level?
______________________________________________________________________________
______________________________________________________________________________
What qualities do you most admire in teachers? (Respond in paragraph form.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Why you have chosen teaching as a career? (Respond in paragraph form.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
EMPLOYMENT BACKGROUND
Job Title Dates/Full or part-time Employer, Location
___________________________ ______________________ ________________________
___________________________ ______________________ ________________________
___________________________ ______________________ ________________________
___________________________ ______________________ ________________________
___________________________ ______________________ ________________________
___________________________ ______________________ ________________________
Do you plan on working during the student teaching placement(s)? Yes____ No____
If yes, indicate type of work, employer, and number of hours per week
______________________________________________________________________________
GENERAL INFORMATION
What is your current health status:
Excellent_________Good________Fair________Poor_______
Indicate any specific health problems that might interfere with your student teaching. _________
_____________________________________________________________________________
3
List the childhood communicable diseases you have not had:
______________________________________________________________________________
______________________________________________________________________________
Check talents or skills which may be assets in your student teaching:
Piano____ First Aid____ Library Science____
Violin____ Home Nursing____ Nature Study____
Singing____ Cooking____ Journalism____
Rhythm Work____ Sewing____ Typing____
Driving Car____ Crafts____ Storytelling____
Speech____ Industrial Arts____
Operating AV Aide____ Leading Recreational Activities____
Underline recreational activities in which you enjoy participating:
Reading, conversation, art, music, dancing, movies, golf, tennis, fishing, riding, hiking, skating,
swimming, hunting, camping, boating, motoring, playing cards, chess, photography, collections,
others________________________________________________________________________
Indicate any classroom practicum and observation experiences that you have had.
School Experience Grade level Date
________________ _________________ _________________ ______________________
________________ _________________ _________________ ______________________
________________ _________________ _________________ ______________________
________________ _________________ _________________ ______________________
________________ _________________ _________________ ______________________
________________ _________________ _________________ ______________________
________________ _________________ _________________ ______________________
________________ _________________ _________________ ______________________
List illustrative materials you have collected for use as teaching aids (such as pictures, slides,
recordings, anthologies, etc.)
______________________________________________________________________________
______________________________________________________________________________
What have you done during the past two summer vacations that have been of value to you?
______________________________________________________________________________
______________________________________________________________________________
Have you traveled? If so, how will your travels be of interest to your students?
Location
Date(s) Special Experiences
___________________ __________________ ________________________________
___________________ __________________ ________________________________
___________________ __________________ ________________________________
___________________ __________________ ________________________________
4
What books (not textbooks) you have read in the past year?
___________________________ ______________________ ________________________
___________________________ ______________________ ________________________
___________________________ ______________________ ________________________
Which magazines do you enjoy reading?
___________________________ ______________________ ________________________
___________________________ ______________________ ________________________
___________________________ ______________________ ________________________
What educational publication(s) do you read?
___________________________ ______________________ ________________________
___________________________ ______________________ ________________________
___________________________ ______________________ ________________________
Have you had experiences (other than related to college course work) in which you worked with
or supervised school age children? If so, please describe:
Experience Dates Description of Experience
___________________ _________________ ________________________________
___________________ _________________ ________________________________
___________________ _________________ ________________________________
___________________ _________________ ________________________________
___________________ _________________ ________________________________
___________________ _________________ ________________________________
___________________ _________________ ________________________________
___________________ _________________ ________________________________
Indicate any additional data that might be significant to your cooperating teacher.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_______________________________________
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InformationFormOld UNIVERSITY OF EVANSVILLE

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Completed 3 November 2019

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