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Supervising Teacher Information Form


Please complete; include your SS# as a small gratuity can not be issued without it. Must be completed before student teaching term begins.


PERSONAL INFORMATION

Date*
First Name*
Middle Name*
Last Name*
SS#*
Home Address*
City*
State*
Zip*
Home Phone
School District*
School Building*
School Address (Street, City, State, Zip)*
School Phone*
Email Address

ACADEMIC BACKGROUND

College attended from which you earned a degree*
Degree Earned*
Year Completed*
College attended from which you earned a degree
Degree Earned
Year Completetd
Major Teaching Field(s)*
Other Teaching Field(s)
Do you hold a valid certificate to teach in Missouri? Life    PC 1    Other   
For which teaching field(s) do you hold a certificate?*

TEACHING EXPERIENCE

Number of years teaching experience, prior to this one in:

Elementary
What grade level?
Secondary
What subject(s)?
K-12 or Other
What subject(s)?
TOTAL (Total must be 3 or more.)*
Number of years in present school district prior to current year?*
Number of student teachers supervised from UCM?*
Number of student teachers supervised from other universities (identify)
During the present school year do you hold a contract as a full time teacher?* Yes    No   
I wish to receive: Stipend
No Stipend
Graduate Credit
Student Teacher's Name*
Semester*

If you are on Career Ladder, please check with your district to determine if receiving credit in lieu of a stipend affects your eligibility.


It is our desire that supervising teachers be interested in cooperating with the student teaching program and that they accept a student teacher willingly. We also appreciate the receipt of this information, which enables us to ascertain the qualifications of all those who help our students complete their professional preparation.