EDUC 509 Recertification Student Teaching Application

This application is due two (2) weeks before the recertification student teaching semester.
It may be submitted up to six (6) months prior to the student teaching semester.
Required twelve (12) hours of coursework must be completed before enrollment of EDUC 509.

Name Name * First Last
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
PSC email *
Phone Phone * - ### - ### ####
List in the next section the dates you plan to complete your student teaching requirement (100 hours=3 full weeks of student teaching in a classroom).

The Director of Field Experiences will coordinate the placement with the school/district.

Note: EDUC 509 is completed after completion of the required twelve (12) hours of coursework.
What term do you plan to complete EDUC 509 recertification student teaching?
What is the date range of when you plan to complete student teaching?
Note: Select three (3) full weeks together.
(Example: August 10-28, 2020)
List in order of priority 3 preferred school districts/buildings in the state of Nebraska.
If you do not have a preference, list no preference.
Describe in detail any personal or professional relationship you have with any of these districts.
Example: relatives working in school/district, kids attend school, worked as a para, etc. )
School/District Contact Person Name if applicable. School/District Contact Person Name if applicable. First Last
School/District Contact Person's Email
School/District Contact Phone Number School/District Contact Phone Number - ### - ### ####
Indicate Teaching Endorsement area
(Example: Elementary Education, Mathematics, Early Childhood, Special Education, etc.)

Grade Preference
Grade Preference	1st Choice	2nd Choice	3rd Choice	No preference
Kindergarten	Kindergarten1st Choice	Kindergarten2nd Choice	Kindergarten3rd Choice	KindergartenNo preference
1st Grade	1st Grade1st Choice	1st Grade2nd Choice	1st Grade3rd Choice	1st GradeNo preference
2nd Grade	2nd Grade1st Choice	2nd Grade2nd Choice	2nd Grade3rd Choice	2nd GradeNo preference
3rd Grade	3rd Grade1st Choice	3rd Grade2nd Choice	3rd Grade3rd Choice	3rd GradeNo preference
4th Grade	4th Grade1st Choice	4th Grade2nd Choice	4th Grade3rd Choice	4th GradeNo preference
5th Grade	5th Grade1st Choice	5th Grade2nd Choice	5th Grade3rd Choice	5th GradeNo preference
Middle Level Grades (6-8)	Middle Level Grades (6-8)1st Choice	Middle Level Grades (6-8)2nd Choice	Middle Level Grades (6-8)3rd Choice	Middle Level Grades (6-8)No preference
Secondary Grades (9-12)	Secondary Grades (9-12)1st Choice	Secondary Grades (9-12)2nd Choice	Secondary Grades (9-12)3rd Choice	Secondary Grades (9-12)No preference

Teacher Education Handbook
(Review recertification information.)

https://www.peru.edu/education/_documents/2022-2023SOEHandbook.pdf
By submitting this application, you verify that you DO NOT have any relatives attending/working within any of the districts/buildings listed above and that you have not attended school in any of the districts/buildings listed above.

If you are requesting an exception to either of these requirements, your request IS clearly noted above, with all pertinent information.

By submitting this application, you also confirm that you have read the Teacher Education Handbook and agree to abide by all policies and procedures therein.

I understand that I must monitor my Peru campus email account frequently; all correspondence regarding my application and placement information will be through my Peru campus email account.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

EDUC 509 Recertification Student Teaching Application

EDUC 509 Recertification Student Teaching Application

Teacher Education Handbook (Review recertification information.) https://www.peru.edu/education/_documents/2022-2023SOEHandbook.pdf

Teacher Education Handbook
(Review recertification information.)

https://www.peru.edu/education/_documents/2022-2023SOEHandbook.pdf