York College - Dept of Ed. - Professional Semester Application

YORK COLLEGE OF PENNSYLVANIA

Department of Education

Application for Permission to Enroll in the Professional Semester

Note fields labeled with an asterisk (*) must not be left blank.

Full Name:*

Student ID Number:*

Social Security Number:*

Email Address:*
(You must use your YCP email address. You may have your YCP email forwarded to another email account. Please see the Student Computer Help Desk for further information.)

Academic Advisor:*

Your academic Major:*

Are you completing a minor? Yes No

If YES, what minor?

Please select one:*

	I seek permission to enroll in Student Teaching.
	I would like to Student Teach in:
	I seek permission to enroll in the Alternate Program.

Semester to be enrolled:* Year:*

Please indicate the ONE level and/or subject area you wish to be placed in:*

	Elementary - Primary (K-3)
	Elementary - Intermediate (3-5)
	Secondary (Middle School/Jr. High) Subject Area:
	Secondary (High School) Subject Area:
	Music Education - Secondary (7-12)
	Music Education - Elementary (K-6)
	Special Education
	Alternate Program - Elementary
	Alternate Program - Secondary

Current address and telephone number:*

City: State:

Zip Code: Phone/Cell Number:

Anticipated Student Teaching address and telephone number:* (Please keep us informed)

City: State:

Zip Code: Phone/Cell Number:

Permanent home address and telephone number:*

City: State:

Zip Code: Phone Number:

High School you graduated from:*

City: State:

10.

Local School District in which you will live during Student Teaching:*

(e.g., YCP on-campus housing = York Suburban SD and YCP off-campus housing such as Jackson Street = York City SD)

11.

Have you ever been paid by a school district?*
Yes No

If YES, which district(s):

12.

Do you have relatives attending or working in a school district?*
Yes No

If YES, which district(s):

13.

Do you intend to engage in extra-curricular activities or to be employed during the professional semester?*
Yes No

(If YES, please describe the extent of such involvement and how you plan to manage such an ambitious program. Use a separate sheet and attach to application.)

14.

Are you now or have you ever been subject to college disciplinary action, or police civil or criminal arrest?*
Yes No

(If YES, please explain fully on a separate sheet and attach to application.)

15.

Are you now or have you been placed on academic suspension or probation at York College?*
Yes No

(If YES, please explain fully on a separate sheet and attach to application.)

16.

Are there any circumstances (geographical, family, economical, physical, or psychological) of which we should be aware that may affect your safety or the safety of the students with whom you will be working?*
Yes No

(If YES, please share with us on a separate sheet, place the separate sheet in a sealed envelope and attach the envelope to the application.)

17.

Are there any responsibilities that you must attend to that will give you problems leaving early in the morning, getting back late in the afternoon, or late in the evening?*
Yes No

(If YES, please explain fully on a separate sheet and attach to application.)

18.

Are there any special considerations or circumstances that we should know about as we try to place you for the Alternate Program or for Student Teaching?*
Yes No

(If YES, please explain fully on a separate sheet and attach to application.)

19.

Are you expecting to:* (Please check the one item that applies to you)

	Graduate at the end of your Alternate Program or Student Teaching
	Complete "Certification-Only" at the end of Student Teaching (already have a Bachelor's degree)
	Complete other coursework during the semester after Student Teaching
	Complete a second Student Teaching during next semester (for Dual Certification Majors)

20.

Will you be applying for Pennsylvania Professional Educator Certification (PA teaching license)?*
Yes No

If NO, are you applying for certification in another state? Yes No
If YES, which state or states?

If YES to PA, are you considering another state? Yes No
If YES, which state or states?

21.

Will you have health insurance through York College of Pennsylvania or another health insurance provider (parents, on your own, etc.)?*
Yes No

If NO, I hereby acknowledge that I have been advised to procure Health Insurance through York College of Pennsylvania or any other health care insurance provider.
(Please sign and date here on printed form)

22.

I understand that a Student Teaching Fee of approximately $230.00 will be added to my tuition bill.

23.

I understand that there is a possibility that I might be placed up to 55 minutes one-away from where I live for my Student Teaching unless I have mitigating circumstances.

24.

I acknowledge that I have been strongly advised not to work, coach, participate in an organization, or to participate in extra-curricular activities during Student Teaching.

25.

I understand that I must obtain and present, to the York College Department of Education, photocopies which are less than a year old on the first day of Student Teaching, for the following:

A medical form or note indicating that I have a negative TB test or chest X-ray
A Pennsylvania State Police Background Check (Act 34)
A Pennsylvania Child Abuse Background Check (Act 151)

26.

I understand that my moral, ethical, and professional behavior is required for the departmental signature on the Pennsylvania Teaching License Application (PDE 338 G) or for any other state's application. These behaviors include all those listed in the York College of Pennsylvania College Catalog under "Qualifications Required for Placement in Student Teaching". Also included by the state of Pennsylvania are illegal use of alcohol and illegal use of drugs.

My signature below indicates that all information contained herein to be true and that I have read and understand all information contained herein.
(Please sign and date here on printed form)

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