Student Teaching Request Form

Overall GPA / Bemidji State University
Bemidji, MN 56601-2699

STUDENT TEACHING REQUEST FORM

/ St. Teaching Semester/Year
Fall / 2017
Catalog Year
Name: (Last) / (First) / (Maiden) / Date:
Local Address: / City/State/Zip / Phone:
Home Address: / City/State/Zip / Phone:
ID # / BSU E-mail
CHECK EACH AREA IN WHICH YOU WILL SEEK TEACHING LICENSURE UPON COMPLETION OF YOUR PROGRAM:
K-6 Elementary Ed / Kindergarten-12 / 5-12:
___ / Health Education
___ / Social Studies endorsement / ___ / Physical Education / ___ / Math
___ / Preprimary endorsement / ___ / DAPE / ___ / Comm/Arts & Lit (English)
___ / Math endorsement / Music / Science
___ / Instrumental and classroom / ___ / Life Science
___ / Vocal and classroom / ___ / Earth & Space
___ / Comm/Arts & Lit. endorsement (English) / ___ / World Language Spanish / ___ / Physics
___ / Science / ___ / Chemistry
Special Ed K-12 Graduate / ___ / Social Studies
___ / EBD / ___ / LD / ___ / Autism
Place the term/year next to the course number you will have successfully completed before you begin student teaching. (This list does not represent a complete list of requirements for licensure.)
FOR ELEMENTARY STUDENT TEACHERS ONLY: /

FOR SECONDARY AND SPECIAL FIELD

STUDENT TEACHERS ONLY:
ED 3100 / Intro to Foundations of Education / ED 3100 / Intro to Foundations of Education
ED 3110 / Educational Psychology / ED 3110 / Educational Psychology
ED 3140 / Human Relations in Education / ED 3140 / Human Relations in Education
ED 3350 / Pedagogy: Planning for Instruction / ED 3350 / Pedagogy: Planning for Instruction
ED 3780 / Adaptation and Management / ED 3780 / Adaptation and Management
ED 4799 / The Professional Teacher / ED 4799 / The Professional Teacher
HLTH 3400 / Health and Drugs in Society / HLTH 3400 / Health and Drugs in Society
ED 4820 / Student Teaching / ED 4737 / Content Area Reading
MATH 1011 / Math for Elem. School Teachers I /

List choice of towns (3) in order of preference:
1.
2.
MATH 1013 / Math for Elementary School Teachers II
ED3201 / Language Arts I
ED 3202 / Language Arts II
ED 3203 / Language Arts III
ED 3221 / Math Methods
ED 3222 / Science Methods
Ed 3240 / Social Studies Methods
ED 3301 / Creative Expressions
ED 3302 / Creative Process Foundations / 3.
HLTH 4100 / Health Methods
PHED 4200 / Physical Education Methods
MTLE/ACT Basic Skills Scores: Reading ______Writing ______Math ______
Elementary Students - Choice of Grades:
High School Diploma from (School and town) and year:
List all grade levels at which you have completed in-class field experiences:
List any special conditions:

Oct. 2015