University of Wisconsin-Stevens Point
Office of Field Experiences
Personal and Professional Data Form
for Prospective Student / Intern Teachers




Name (LAST, FIRST, INITIAL):


Sex: 


Local address (STREET, CITY, ZIP):

Phone:


E-mail:                           Home Page:



Home address (STREET, CITY, ZIP):

Phone:


High school attended (NAME, LOCATION, GRAD DATE):  


Colleges and universities attended (INDICATE INCLUSIVE DATES AND
DEGREES RECEIVED):





Teaching major(s)

Teaching minor(s)




Courses completed or in progress in your teaching major(s), minor(s), and professional education program.  (LIST COURSES BY  DESCRIPTIVE TITLE, NOT COURSE NUMBER; I.E., LIST GENERAL BIOLOGY, NOT BIOLOGY 101.)


Major courses:









Minor courses:









Professional Education Courses:









Field experience placements (SITE, GRADE LEVEL, COOPERATING TEACHER):






Experiences in observing or directing the activities of children/youth (INCLUDING BABYSITTING, STORYTELLING, SERVING AS A PLAYGROUND SUPERVISOR, TEACHER ASSISTANT OR TEACHER'S AIDE, REFEREEING, COACHING, ETC.):








Work experiences (INDICATE THE POSITION OR NATURE OF THE WORK, FULL OR PART-TIME, MONTH & YEAR):







Extracurricular activities and community organizations (GIVE MONTH & YEAR, OFFICES HELD):






Sports, hobbies or recreation interests:




Major travel experiences (GIVE MONTH & YEAR):




If employed, hours per week and type of work:

Place of employment:



Skills (MUSIC, ART OR OTHERS):







Preferred teaching experiences: (SPECIFY AGES, GRADES & SUBJECT AREAS, NOT PLACES)
 










School extracurricular activities I'd be available to help (CLUBS, HOMEROOMS, SPORTS PROGRAMS, ETC.):









Additional personal information (INCLUDING MEDICAL CONDITIONS OR PHYSICAL RESTRICTIONS):








I affirm that the information provided is accurate and grant the release of this information for the purpose of arranging a student teaching/internship assignment.


Signed________________________________________Date_______________