1 Start 2 Page Break 3 Complete I am applying for * Spring 2021 Fall 2021 Last Name * First Name * Middle Initial Present cohort site * Phone * UA Student ID * Local Address (Apt. No) * City/State/Zip * Permanent Address (Apt No) Permanent City/State/Zip UA Email * Alternative Email Have you ever been convicted or pled “No Contest” for any violation of the law other than minor traffic violations? * Yes No Race/Ethnicity - None -African AmericanHispanicAsian American/Pacific IslanderAmerican Indian/Alaskan NativeWhite Current Semester Status * Undergraduate Post-Baccalaureate Are you an international student? * Yes No Seniors, please identify your preschool and elementary placement sites & mentors. Juniors identify your current site. In the event that a previous practicum placement is not available as a student teaching placement, we would like to know your preferences. Please describe below any district, school or teacher placement you may prefer and why. Grade level preference - seniors only 123 K K - 1 K - 2 K - 3 1st 1st - 1 1st - 2 1st - 3 2nd 2nd - 1 2nd - 2 2nd - 3 Student Teaching Placement Policy I understand it is against University policy to be placed for student teaching where my children attend school or relatives are employed. * Yes No Permission for Release of Information School Districts frequently request student information for student teaching placements and job opportunities. This may include, but is not limited to name, address, phone number, email, student teaching packet information, and unofficial transcripts. * I authorize the Director of Student Services and/or the Director of Field Experiences to release information for placement and job opportunities. I DO NOT authorize the Director of Student Services and/or the Director of Field Experiences to release information for placement and job opportunities. Leave this field blank Next Page >