Dear Physician/Health Care Provider:
State health regulations require that all applicants for school-based fieldwork (Student Teaching) provide
written proof of a current health certificate form.
This candidate is applying to enroll in student teaching. This is the long-term, school-based, supervised field
experience that occurs at the end of a teacher preparation program. A student teacher is required to assume an
active role in the instruction of children/youth over a period of several months. In addition to the technical
and intellectual abilities required, a student teacher must also possess the physical stamina and emotional
stability required of a classroom teacher.
Due to the length of the experience and the level of responsibility that must be assumed, all student teachers
must be screened before they are given final approval to begin working in schools. The Health Certificate
below is part of the screening process. Thank you for your assistance.
IMPORTANT NOTICE ABOUT THIS DOCUMENT:
For identification, the health care provider signing this certificate should also submit one of the
following:
1. signed voided prescription form
2. signed letterhead with patient’s name and date of office visit
3. office stamp with name of provider’s office and address
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HEALTH CERTIFICATE FOR TEACHER PREPARATION STUDENTS
Date: ____________
This is to certify that the applicant, _______________________________ , has been examined and is known by me
to be free from any physical or emotional condition that might interfere with his/her success as a student teacher. If no
restrictions, please indicate “None”.
Restrictions: _____________________________________________________________________
Name of Facility: __________________________________________________________________
Name of Health Care Provider: ________________________________________________________
Signature of Health Care Provider:
Please return the signed certificate to the applicant, or mail directly to:
Keira Potter, Compliance Manager
Office of Clinical Studies
Wilmington University
3282 N. DuPont Hwy.
Dover, DE 19901
Telephone: (302) 342-8608
Fax: (302) 734-1331
E-mail:
keira.m.potter@wilmu.edu
