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					                          DUE to PROGRAM COORDINATORS October 1, 2009
                                                 (Heal th Form due in Poe 204 October 1, 2009
            INSTITUTION OF                                ASSIGNMENT REQUEST                                     ASSIGNMENT REQUEST
      HIGHER LEARNING                                             (IHE complete in pencil)                                  (IHE complete in pencil)
                                                      1. Cooperating Teacher/Supervisor :                      2. Cooperating Teacher/Supervisor :
       North Carolina State                           _______________________________                          _______________________________
           University                                 1. Subject and/or Grade:                                 2. Subject and/or Grade:
                                                      _______________________________                          _______________________________
                                                      1. Schoo l:                                              2. Schoo l:
     PARTICIPATING AGENCY                             _______________________________                          _______________________________
                                                      Confirmed:                                               Confirmed:




                                      TRIANGLE ALLIANCE
                                     APPLICATION FOR STUDENT TEACHER OR INTERN
                                                         PLEASE TYPE OR PRINT
Name
        Mr./Mrs./Miss/Ms.         Last                            First               Middle                     Maiden                 Prefer to be called


Student ID Nu mber ________________________


SSN#*                                                                Date of Birth                                              Race
                                                                                               Mo        Day       Yr                        (Optional)

* I am voluntarily providing my social security # with the understanding that it will be used only as a personal identifier for teacher licensure and reporting
purposes as required by the North Carolina Department of Public Instruction .

ADDRESS INFORMATION
Local/College (if applicable)                                                                                                   Phone
Permanent/Home                                                                                                                  Phone


E-Mail_____________________________________________________________________________

LICENSURE INFORMATION
Area and/or Level(s) of licensure desired (e.g., Middle Grades Math [6-9], Secondary Science [9-12]):

Anticipated graduation/completion date:

Expected degree: Bachelor’s ____Master’s _____ Doctorate                                                Licensure-Only_______

STUDENT TEACHING/GRADUATE INTERNSHIP-Check one
Spring 2010 _____________________
Fall 20 10 __________________

Dates of Full Time Assignment: From _____________________ to ______________________
First day to report for observation: _________________________________________________



Revised 1/09
EDUCATION
(Provide School Name, City/County, State)

Undergraduate (if graduate student):
High School:
Middle/Junior High:
Elementary:
EMERGENCY CONTACTS

     Name                                      Relationship                      Day Phone           Evening Phone


     Name                                      Relationship                      Day Phone           Evening Phone



HEALTH (Health Form must be completed and submitted.)
Have you been under a doctor’s care during the past two years? _______Yes _______No
If “YES,” explain briefly.


TRANSPORTATION PROBLEMS?                                             Yes    No   If “YES,” explain briefly.
___________________________________________________________________________________

                                               PLEASE NOTE
1.   Student teachers/interns are expected to abide by the participating agency’s calendar and by all the
     schedules and policies in effect in the school to which they are assigned.
2.   Student teachers/interns will receive no financial remuneration for the student teaching/intern
     experience.
3.   Student teachers/interns will be assigned to schools without regard to the sex or race of the applicant.
4.   Student teachers/interns may be required to complete a criminal background check at the students’
     expense.


                    Signature of Student Teacher/Graduate Intern                                        Date



                      RECOMMENDATION OF INSTITUTIONAL REPRESENTATIVE


              Signature of Institution of Higher Education Representative                               Date




Revised 1/09
                             DUE IN 204 POE October 1, 2009
                              North Carolina Public Schools
            Student Teaching/Graduate Internship Health Examination Certificate
Required of all persons upon initial employment, or separation from employment more than one school year, or deemed necessary by a local
school board or superintendent. This certificate must be completed and signed by a physician licensed to practice medicine in the State of
North Carolina (NCGS §115C-323). For student teaching purposes, this information may be provided by an out-of-state physician.


Name
Social Security Number                                                 Subject Area
Address
                                                                                        Telephone:
The above named individual is to be reco mmended for emp loy ment by
(local school board) in a position of student teacher/graduate intern. In this position, the condition of certain physical
capacities will be of importance. Please examine the areas listed below and report any limitations, deficiencies or related
restrictions.
           AREAS                                  LIMITATIONS                               NATURE OF LIMITATIONS

                                            YES                         NO
Vision

Hearing

Heart

Lungs

Lift ing/Carry ing

Other



TB Test Information
Result (circle one): POSITIVE NEGATIVE
Test Date:
                                     Name of person admin istering TB test (please type/print)


                                                                      Telephone Number
Signature

By my signature I certify that the above named person does not have any communicable disease, including tuberculosis, that
poses a significant risk of transmission in our schools or would impair this person’s ability to perform the duties of the jo b,
except as may be noted above. Further I cert ify that this person is free of any physical or mental d isability that would impair
job performance.

If unable to cert ify, p lease comment:




Date                                      ___________________________________ _______________________________
                                               Physician name (please type/print) Telephone Number


Physician’s Signature___________________________________________________ M.D.
Revised 1/09
           Specific Information Regarding TB Tests
                              and
                         Health Forms
                                 TB Tests
Every student teacher must have a TB test that is less than one year old at
the time s/he begins student teaching. For example, a student beginning
student teaching in September 2010 must have a signed TB test form dated
no earlier than August 13, 2009. A student beginning student teaching in
January 2010 must have a signed form dated no earlier than December 1,
2009.



           Health Forms Are Due in 204 Poe
                  By October 1, 2009




Revised 1/09

				
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