EmailMeForm
Student Teaching Application Form
AY 2026 - 2027
(Must have a Cumulative GPA of 2.5 or higher.)
Student ID #:
*
Name
*
First
Last
Campus Box Number:
*
Email
*
Cell Phone:
*
###
-
###
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Hometown State:
*
Do you plan to return to this state to teach after Wartburg graduation?
*
Yes
No
Not Sure
Housing while Student Teaching:
*
On Campus
Off Campus
Not sure yet.
When do you plan to Student Teach?
Fall 2026
Winter 2027
Location of Student Teach?
(If anything other than Local, email School Partnerships Coordinator, stephanie.moeller@wartburg.edu)
*
Local to Campus
Des Moines
At-A-Distance
If At-A-Distance where?
Have you met your 25-hour Diverse Cultural Experience?
*
Yes
No
Not sure?
If Yes, where? (List school)
If No, do you want to complete the 25-hours of diversity in Ed Psych or during one of your ST placements?
What is your Major:
*
Elementary
Secondary
PE
Music
List All Endorsement/Content Areas: (Examples: EC, Health, All Sciences, Math, Special Ed.)
*
List top 3 Preferred Grade Levels: (Example: 1st, K, 5th)
*
If a specific teacher previously requested that you student teach with them, please indicate their name, grade, and school below.
Background Information. Please attach an explanation if you answered "yes" to any of the following violations.
Have you ever been convicted of a felony?
Yes
No
Have you ever been convicted of a crime other than a parking or speeding violation?
Yes
No
Do you currently have any criminal charges pending against you?
Yes
No
Have you ever had a founded report of abuse made against you?
Yes
No
Wartburg Student Teacher Signature:
*
Clear
Date
MM
/
DD
/
YYYY
Print form with Education Coordinator and add Advisor's Signature(s):
(Advisor signature represents a positive recommendation for this individual as a prospective member of the profession. I believe this person possesses ethical and moral values consistent with professional standards promoted by the College and for teacher licensure, as well as, human qualities that will elicit positive responses from stakeholders.)
If as an Advisor, you have concerns about this student Student Teaching, please do not sign and contact the Education Office.
Clear
If Music, you must get your Advisor's signature above plus either Dr. Toliver's or Dr. Muntefering's signature here:
Clear
Date
MM
/
DD
/
YYYY
For Department Use Only:
GPA:
Diversity Met: Yes No
Admitted into TEP: Yes No
____________________________
FE approved: Yes No
MUSIC ONLY:
Jr. Recital: Yes No
Piano Proficiency: Yes No
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Comments:
