EmailMe Form - Student Teaching Application Form

Student ID #: *

Name *

First Last

Campus Box Number:

Email *

Cell Phone: *

### - ### - ####

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 2027

Winter 2028

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 or schools)

If No, if possible, 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.
Obtain 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.
As Advisor - you've checked the applicants Advising Worksheet to validate academic eligibility to ST.
If as an Advisor, you have concerns about this student Student Teaching, please do not sign and contact the Education Office.

Clear

Date of Advisor's signature:

MM / DD / YYYY

If Music, and your Advisor is not Dr. Toliver or Dr. Muntefering, you must get one of them to sign as well, respectfully either Vocal or Instrumental:

Clear

Date of signature:

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
__________________________________

Comments: