SOUTHERN CONNECTICUT STATE UNIVERSITY
STUDENT TEACHING APPLICATION
FOR SCHOOL MEDIA SPECIALISTS

[Please print or type]

 

Name:

 

Social Security Number:

 

Home Address:

 

Home Phone Number:

 

Email Address:

 

Praxis I:
Passed: Yes ______ No _____ To be Taken (date) _______________

 

Waived _____ Date when applied for waiver ____________________

 

 

Selection of Student Teaching Period: Fall 200___ Spring 200___

 

 

Town(s) where you attended school:

 

Elementary _________________________ Secondary _________________________
[indicate if public or private school]

 

 

Transportation: Auto _____ Public _____ Other (specify) __________

 

 

Check 3 choices ­ These choices merely indicate a general area preference. There may not be a BEST-trained school media specialist in this location.]
Ansonia __________ East Haven __________ New Haven __________ Southington __________
Beacon Falls __________ Fairfield __________ North Branford __________ Stratford __________
Bethany __________ Guilford __________ North Haven __________ Trumbull __________
Branford __________ Hamden __________ Orange __________ Wallingford __________
Bridgeport __________ Madison __________ Oxford __________ Waterbury __________
Cheshire __________ Meriden __________ Portland __________ West Haven __________
Clinton __________ Middletown __________ Prospect __________ Westbrook __________
Derby __________ Milford __________ Seymour __________ Wolcott __________
Deep River __________ Naugatuck __________ Shelton __________ Woodbridge __________
Durham/Mdlfd __________

THIS FORM MUST BE COMPLETED BY EVERY STUDENT REQUESTING STUDENT TEACHING PLACEMENT.
Return this completed form and the Personal and Professional Data form to the Library School office
at least six months prior to the term in which you wish to student teach.