STUDENT TEACHING APPLICATION

http://www.bloomu.edu/documents/coe/student_teaching_packet.pdf STUDENT TEACHING APPLICATION Early Childhood PK-4/Middle Level 4-8, Secondary Education, Dual Special Education PK-8/Early Childhood PK-4 and Deaf Hard of Hearing Candidates applying for student teaching must meet eligibility requirements and submit required documentation to the Office of Field Experiences (McCormick 3103-C) by the following due dates: Fall Student Teaching Placement All documentation due May 1 st Spring Student Teaching Placement All documentation due October 1 st Student Teaching Eligibility Requirements: 1. Application for Graduation completed and signed by your advisor 2. *Tuberculosis (TB) Results must be valid for the duration of the student teaching semester (Attach 3 copies) 3. **Act 34 (Criminal Record Check) must be valid for the duration of the student teaching semester (https://epatch.state.pa.us/) (Attach 3 copies) 4. **Act 151 (Child Abuse History) must be valid for the duration of the student teaching semester (Attach 3 copies) (https://www.compass.state.pa.us/cwis/public/home) 5. **Act 114 (Federal Criminal History) must be valid for the duration of the student teaching semester (http://www.cogentid.com/index.htm) must register through Department of Education (Attach Registration Receipt ONLY) after fingerprinted. 6. **Act 24 (Arrest/Conviction Report and Certification Form) (Attach 3 copies) 7. Professional Liability Insurance must be valid for the duration of the student teaching semester and must meet a minimum of $1,000,000.00 per claim and $3,000,000.00 aggregate (http://www.psea.org) (Attach 3 copies) 8. Resume 9. Student Teaching Placement Agreement signed and dated 10. ***Act 126 (Mandated Child Abuse Reporting obtained through www.reportabusepa.pitt.edu Free On- Line training or register through Bloomsburg University for the amount of $20.00 for a more in-depth training session (Print Certificate) (Attach 3 Copies) *TB Results are valid for ONE year from screening results date. NOTE: Some Districts may require it to be within 3 months prior to placement start date. You will be notified once placement has been confirmed. **Act 34, 151, 114 are valid for ONE year from date issued. Any infraction reported on any clearance will result in the placement process being delayed. Candidates will be notified and be responsible to schedule a Program Review Counseling Session with the College of Education s Assistant to the Dean where information and guidance will be provided to assist the candidate in understanding how infractions may affect student teaching placement, program progression, certification, and future employment success. ***Act 126 valid for FIVE years from date issued. Revised Spring 2010/Spring 2012/Spring 2013/Fall 2013/Fall 2014/Fall 2015

Student Teaching Application and Verification of Eligibility Early Childhood PK-4/Middle Level 4-8, Secondary Education, Dual Special Education PK-8/Early Childhood PK-4 and Deaf Hard of Hearing Candidates are responsible for completing student teaching eligibility requirements and are expect to meet with their designated academic advisor(s) for program guidance and verification that application requirements have been met. It is then the responsibility of the candidate to deliver this application, completed and with advisor s signature, to the Office of Field Experiences (McCormick 3103-C) by the appropriate date: Fall student Teachers May 1 st Spring Student Teachers Due October 1 st Candidate s Name: Identification Number Eligibility for Student Teaching is contingent upon evidence of the following: 1. 2. 3. 4. 5. 6. 7. 8. 9. Professional Liability Insurance (Attach 3 copies) Options: private carrier, professional organizations or PSEA (http://www.psea.org) Documentation of Act 34 (Criminal Record Check) must be valid for duration of student teaching or practicum semester (Attach 3 copies) (http://epatch.state.pa.us) Documentation of Act 151 (Child Abuse History) must be valid for duration of student teaching or Practicum semester (Attach 3 copies) Documentation of Act 114 (Federal Criminal History) must be valid for duration of student teaching or practicum semester (Attach Registration Receipt ONLY) after fingerprinted. Register at (http://www.pa.cogentid.com) MUST register through, The Department of Education. Documentation of Act 23 (Arrest/Conviction Report and Certification Form - student teacher eligibility (Attach 3 copies) Documentation of tuberculosis test results (TB) (Attach 3 copies) Updated resume Application(s) for Graduation (Attach signed application) Secondary Education candidates will need a signed application from two advisors (ESSE program/content major) Documentation of Act 126 (Mandated Child Abuse Reporting) (Attach 3 copies) The following signature attests that all documents are accurate, updated and attached: Advisor/Faculty Date Conditionally Recommended (If checked, explain below) Revised Spring 2010/Spring 2012/Spring 2013/Fall 2013/Fall 2014/Fall 2015

http://www.bloomu.edu/documents/coe/student_teaching_packet.pdf College of Education Student Teaching Agreements Please read the student teaching terms below. Provide the requested information, initial, and sign where indicated to acknowledge your agreement to the terms and deadlines. I, hereby acknowledge to the Office of Field Experiences, Bloomsburg University of Pennsylvania: that I have read and understand that the Student Teaching Eligibility Packet deadline is firm as set forth in the packet. I bear all responsibility for the submission of my student teaching packet by the deadline date being considered for student teaching. (initial) that I give consent to the Office of Field Experiences to release any and all records it may have in its possession to a school district or other site in which I may be placed for student teaching or practicum in order to prove my qualifications. I realize that such records may include and not be limited to, academic (GPA and courses completed), health (TB screening results), Act 34, Act 151, and Act 24 clearances and disciplinary records, as well as my social security number and Bloomsburg University of Pennsylvania identification number for identification purposes. Bloomsburg Univesrity will supply the Act 114 Registration ID# to the District only. This release will expire upon commencement from Bloomsburg University of Pennsylvania or after completion of student teaching or practicum, whichever is later. (initial) that as an enrolled student at Bloomsburg University of Pennsylvania, I have read and will comply ************************** with : College of Education, Admission, Monitoring and Monitoring and Exit Procedures for Teacher Education Initial Certification Programs, College Policy 3.0 (http://www.bloomu.edu/documents/coe/policyhandbook.pdf) (initial) I realize that by signing the above acknowledgments, I agree to adhere to the terms and deadlines set forth and failure to do so will result in the postponement of my student teaching experience. Candidate s Signature: Candidate s Printed Name: Date: Revised Spring 2010/Spring 2012/Spring 2013/Fall 2013/Fall 2014

Teacher Candidate Placement Agreement This agreement is entered in between and the Office of Field Experiences at Bloomsburg University of Pennsylvania, located in the McCormick Building, third floor. Bloomsburg University of Pennsylvania has a great reputation for placing our teacher candidates in a variety of districts in which we have fully signed/executed affiliation agreements in place. The Office of Field Experiences will do everything possible to assure the experience is successful and positive for our aspiring teacher candidates. We cannot guarantee you will be placed within a 30-mile radius of your residency. Your student teaching placement may be up to 2 hours from the address you provided on the Student Teaching Placement Card (Application for Student Teaching). There may be isolated situations where housing on campus is necessary in order to provide a placement for you. If you change your place of residency, you MUST contact the Office of Field Experiences immediately at amccabe@bloomu.edu or 570-389-5128. (Fall Prior to May 1 st ; Spring Prior to October 1 st ). Direct contact to districts, initiated by you, family or someone on your behalf can result in termination of student teaching placement for a semester. It is the Field Experience Placement Office s policy that all agreements and affiliations with district placements are conducted through the Office of Field Experiences ONLY. We value the support and relationships of our participating school partners and are honored to continue placing quality, professional teacher candidates in their facilities. Thank you for understanding and acknowledging this agreement. The professional growth and quality experience that you will gain through your placement will contribute greatly to the effectiveness of your career. The Office of Field Experiences is always opened to provide you with support and guidance. Be a lifelong learner, it is the continual knowledge you seek that will enhance the students your encounter and prepare you for the continuous changes in the education profession. Thank you, Candy Ryan Director of Field Experiences I have carefully read the above contract and agree to abide by the terms listed: Signature: Date:

1 of 3 ARREST/CONVICTION REPORT AND CERTIFICATION FORM (under Act 24 of 2011 and Act 82 of 2012) Section 1. Personal Information Full Legal Name: Any former names by which you have been identified: Date of Birth: / / Section 2. Report of Arrest or Conviction By checking this box, I report that I have been arrested for or convicted of an offense or offenses enumerated under 24 P.S. 1-111(e) or (f.1) ( Reportable Offense(s) ). See Instructions on Page 3 of this Form for a list of Reportable Offenses. If you have none to report, proceed to Section 3 of this form. Details of Arrests or Convictions For each arrest for or conviction of any Reportable Offense, specify in the space below (or on additional attachments if necessary) the offense for which you have been arrested or convicted, the date and location of arrest and/or conviction, docket number, and the applicable court. Section 3. No Arrest or Conviction By checking this box, I state that I have not been arrested for or convicted of any Reportable Offense. Section 4. Certification By signing this form, I certify under penalty of law that the statements made in this form are true, correct and complete. I understand that false statements herein, including, without limitation, any failure to accurately report any arrest or conviction for a Reportable Offense, shall subject me to criminal prosecution under 18 Pa.C.S. 4904, relating to unsworn falsification to authorities. Signature Date PDE-6004 (8/28/2012)

2 of 3 INSTRUCTIONS This standardized form (PDE-6004) has been developed by the Pennsylvania Department of Education, pursuant to 24 P.S. 1-111(j), to be used by current and prospective employees of public and private schools, intermediate units and area vocational-technical schools for the written reporting by current and prospective employees of any arrest or conviction for an offense enumerated under 24 P.S. 1-111(e) and (f.1). As required by subsection (j)(2) of 24 P.S. 1-111, this form shall be completed and submitted by all current and prospective employees of a public or private school, intermediate unit or area vocational-technical school. In addition, as required by subsection (j)(4) of 24 P.S. 1-111, this form shall be utilized by current and prospective employees to provide written notice within seventy-two (72) hours after an arrest or conviction for an offense enumerated under 24 P.S. 1-111(e) or (f.1). Exemption: Any current employee who completed a PDE-6004 on or before December 27, 2011, in compliance with 24 P.S. 1-111(j)(1) and (2) on that date, and who has not been arrested for or convicted of an offense enumerated under 24 P.S. 1-111(e) and (f.1) shall not be required to complete an additional form. In accordance with 24 P.S. 1-111, employees completing this form are required to submit the form to the administrator or other person responsible for employment decisions in a school entity. If you have questions regarding to whom the form should be sent, please contact your supervisor or the school entity administration office. PROVIDE ALL INFORMATION REQUIRED BY THIS FORM LEGIBLY IN INK. PDE-6004 (8/28/2012)

3 of 3 LIST OF REPORTABLE OFFENSES A reportable offense enumerated under 24 P.S. 1-111(e) consists of any of the following: (1) An offense under one or more of the following provisions of Title 18 of the Pennsylvania Consolidated Statutes: Chapter 25 (relating to criminal homicide) Section 2702 (relating to aggravated assault) Section 2709.1 (relating to stalking) Section 2901 (relating to kidnapping) Section 2902 (relating to unlawful restraint) Section 2910 (relating to luring a child into a motor vehicle or structure) Section 3121 (relating to rape) Section 3122.1 (relating to statutory sexual assault) Section 3123 (relating to involuntary deviate sexual intercourse) Section 3124.1 (relating to sexual assault) Section 3124.2 (relating to institutional sexual assault) Section 3125( relating to aggravated indecent assault) Section 3126 (relating to indecent assault) Section 3127 (relating to indecent exposure) Section 3129 (relating to sexual intercourse with animal) Section 4302 (relating to incest) Section 4303 (relating to concealing death of child) Section 4304 (relating to endangering welfare of children) Section 4305 (relating to dealing in infant children) A felony offense under section 5902(b) (relating to prostitution and related offenses) Section 5903(c) or (d) (relating to obscene and other sexual materials and performances) Section 6301(a)(1) (relating to corruption of minors) Section 6312 (relating to sexual abuse of children) Section 6318 (relating to unlawful contact with minor) Section 6319 (relating to solicitation of minors to traffic drugs) Section 6320 (relating to sexual exploitation of children) (2) An offense designated as a felony under the act of April 14, 1972 (P.L. 233, No. 64), known as The Controlled Substance, Drug, Device and Cosmetic Act. (3) An offense SIMILAR IN NATURE to those crimes listed above in clauses (1) and (2) under the laws or former laws of: the United States; or one of its territories or possessions; or another state; or the District of Columbia; or the Commonwealth of Puerto Rico; or a foreign nation; or under a former law of this Commonwealth. A reportable offense enumerated under 24 P.S. 1-111(f.1) consists of any of the following: (1) An offense graded as a felony offense of the first, second or third degree, other than one of the offenses enumerated under 24 P.S. 1-111(e), if less than (10) ten years has elapsed from the date of expiration of the sentence for the offense. (2) An offense graded as a misdemeanor of the first degree, other than one of the offenses enumerated under 24 P.S. 1-111(e), if less than (5) five years has elapsed from the date of expiration of the sentence for the offense. (3) An offense under 75 Pa.C.S. 3802(a), (b), (c) or (d)(relating to driving under influence of alcohol or controlled substance) graded as a misdemeanor of the first degree under 75 Pa.C.S. 3803 (relating to grading), if the person has been previously convicted of such an offense and less than (3) three years has elapsed from the date of expiration of the sentence for the most recent offense. PDE-6004 (8/28/2012)

Bloomsburg University of Pennsylvania Commencement Office Carver Hall APPLICATION FOR GRADUATION (UNDERGRADUATE) INSTRUCTIONS: A candidate for a bachelor s degree must complete the front of this form and submit to his/her department for verification of degree requirements. Secondary Education, double major, and dual degree students must submit two applications. The department/s will then review and approve/deny and submit the application to the Graduation Coordinator. If you have NOT met all requirements for graduation, your department will notify you. MAY GRADUATION: Deadline for student submission of this form is FEBRUARY 1 in order to be eligible to participate in the commencement ceremony, for your name to be listed in the commencement program, for recognition of honors at the ceremony, and for a diploma to be ordered in your name. The department must submit this application to the Graduation Coordinator by MARCH 15. *AUGUST GRADUATION: (There is no August commencement ceremony. Instead, August degree candidates may elect to walk in the May ceremony or to walk in the December ceremony. Select choice below.) Deadline for student submission of this form is MARCH 1 in order to be eligible to participate in the commencement ceremony, for your name to be listed in the commencement program, for recognition of honors at the ceremony, and for a diploma to be ordered in your name. The department must submit this application to the Graduation Coordinator on or before APRIL 1. DECEMBER GRADUATION: Deadline for student submission of this form is OCTOBER 1 in order to be eligible to participate in the commencement ceremony, for your name to be listed in the commencement program, for recognition of honors at the ceremony, and for a diploma to be ordered in your name. The department must submit this application to the Graduation Coordinator on or before NOVEMBER 1. *************************************************TO BE COMPLETED BY STUDENT ***************************************** Student ID Number PRINT your name as you want it to appear on your diploma and in the commencement program PHONE: ( ) - (Where you can be reached if there are questions about your graduation.) E-MAIL ADDRESS: Which semester will you complete all requirements for your degree? (If this date changes, contact the Graduation Coord.) Spring Semester 20 *Summer Semester 20 Fall Semester 20 AREA OF STUDY: Indicate your major, with concentration area if appropriate. (List only one major on this form. Complete another application if you are in secondary education, a double major or a dual degree student.) Business: Liberal Arts: Major: Major: Education: Major: Sec. Ed. 2nd Major: Science & Technology: Major: DO YOU PLAN TO PARTICIPATE IN THE COMMENCEMENT CEREMONY? (If neither box is checked, your name will be recorded as not participating.) YES NO *AUGUST GRADUATES: Which ceremony do you plan to attend: May December Not participating

Student Name: Last First MI ************************************************** DEPARTMENT APPROVAL******************************************************** (This section is to be completed by the department of the major noted on the reverse.) DEGREE PROGRAM: BA BS BSBA BSED BSN BSW MAJOR (INCLUDE CONCENTRATION): Cum. Credits Earned: 1. Will all curricular requirements for the MAJOR be completed by the time of graduation? YES NO, give explanation below 2. Has student taken developmental studies courses numbered 001 099? YES (Credits do not count toward graduation) NO 3. Will all requirements for the following General Education SPECIFIC areas be completed by the end of the semester indicated on the reverse? a. COMMUNICATION YES NO, give explanation below b. QUANTITATIVE - ANALYTICAL REASONING YES NO, give explanation below c. VALUES, ETHICS & RESPONSIBLE DECISION MAKING YES NO, give explanation below d. FITNESS & RECREATIONAL SKILLS YES NO, give explanation below 4. Will all of the following General Education DISTRIBUTION Requirements be completed by the end of the semester indicated? a. GROUP A - HUMANITIES YES NO, give explanation below b. GROUP B - SOCIAL & BEHAVIORAL SCIENCES YES NO, give explanation below c. GROUP C - NATURAL SCIENCES AND MATHEMATICS YES NO, give explanation below 5. Will the Cultural Diversity Requirement be completed by the end of the semester indicated? YES NO, give explanation below 6. At this time, does the candidate have the following: a. 2.00 grade point average in all courses for the MAJOR? YES NO (THE REQUIRED GPA IN SOME DISCIPLINES MAY BE HIGHER THAN 2.0) b. 2.00 cumulative grade point average in all courses? YES NO 7. Are there any outstanding grades of I and/or R that need to be completed? NO YES 8. Are there any outstanding transfer credits that are required for the degree? NO YES, Prior Approval of Transfer Credit form completed IT IS THE RESPONSIBILITY OF THE ADVISOR OR DEPARTMENT CHAIRPERSON TO NOTIFY THIS DEGREE CANDIDATE OF ANY COURSE DEFICIENCIES OR IF GRADUATION APPROVAL IS DENIED. I certify that this student is cleared for graduation, with the successful completion of the current semester (and/or the courses noted below). This candidate is NOT cleared for graduation. Student was notified. DEPARTMENT APPROVAL: DATE: CHAIR OR DESIGNEE Explanation of course requirement/s to be completed before bachelor s degree can be granted:

APPLICATION FOR GRADUATION for MASl 'ER'S, DOCTORATE, OR GRADUATE CERTIFICATES INSTRUCTIONS: This form is to be used only if you are ready to graduate with one of the degrees/certificates listed above. A candidate for a master' s/doctorate/certificate program must complete the student portion of this form, sign, and submit it to their program coordinator [or verification o[degree requirements. Once approved, the program coordinator must forward it directly to the Graduate Office (with the appropriate program check sheet) by the deadline listed below for each degree (regardless if you are or are not participating in a commencement ceremony). MAY DEGREE: ~ The application must be in the Graduate Office on or before MARCH 15. After this deadline, names may not be placed in the commencement program. Diploma will be delayed. AUGUST DEGREE: *(There is no August commencement ceremony. August degree candidates, may "walk " in the May ceremony or participate in the December ceremony.) ~ The application must be in the Graduate Office on or before APRIL 1 for participation in May ceremony. After this deadline, names may not be placed in the commencement program. Ifnot participating in the May ceremony, the application must be in the Graduate Office by August I. DECEMBER DEGREE: ~ The application must be in the Graduate Office on or before OCTOBER 15. After this deadline, names may not be placed in the commencement program. Diploma will be delayed. PARTICIPA TION IN THE COMMENCEMENT CEREMONY DOES NOT CONS TITUTE VERIFICA TION OF GRADUATION. A STUDENT MUST SATISFACTORILY COMPLETE ALL REQUIREMENTS BEFORE A DEGREE IS AWARDED. Failure to meet the requirements by the semester indicated on the submitted application will require resubmission ofa new "Applicationfor Graduation "for whenever requirements will be met. Visit the Registrar's webpage for Graduation/Ceremony information: http://www.bloomu.edu/registrar. Rev. 10/08 See other side..

APPLICATION FOR GRADUATION (Master's, Doctorate or Graduate Certificates) *********************************TO BE COMPLETED BV STUDENT********************************* DDDDDD BU Student 10 PRINT NAME (as you would like it to appear on your diploma) Which semester will you complete all requirements (including departmental paper, thesis, internship, etc.) for your degree? (Fai lure to meet the requirements by the semester checked below will require you to reapply when requirements will be mel) rjspring Semester (May) 20 D*Summer Semester (August) 20 D Fall Semester (December) 20._------- -------------- l!. Program of Study: I IDegree/ certi fica te be i ng sou ght : :-:-::----:-:-:--:-::-_-::-:-:-----::---_--:-::-_-::-:_----:-::- -,--- (MS.. M.Ed., MBA, MSN, AuD, or certificate/list certificate program) 00 you plan to participate in graduation: Wear a cap and gown, march with the class, receive your diploma cover and be hooded on stage? aves 0 NO (If there is not a box checked. your name will be recorded as NOT participating.) "'August Graduates: Which ceremony do you plan to attend : OMay 20 0 DDecember 20 CI Dr do not plan to attend any ceremony. Theses presented for degrees are printed in the commencement program. If applicable, please PRrNT the title of thesis and name of your thes is advisor here: THESIS TITLE: THESIS ADVISOR: I X------ - S- t-u-d-en-t-'-s-s-ig-n-a-tu- r-e--- --------- DATE:... TO BE COMPLETED BY PROGRAM COORDINATOR FOR APPROVAL-----------_.._----_..... IT IS THE PROGRAM COORDINA TOR 'S RESPONSIBILITY TO NO TlFY THE DEGREE CANDIDA TE OF ANY DEFICIENCIES D [ certify that this degree candidate is cleared for graduation. A completed checksheet must accompany the application. Program Coordinator:, DATE: Approved for Degree Granting: Dean of Graduate Studies & Research DATE: _ Rev 10108 See other side