Fall 2008 Secondary Student Teacher & Intern Information Request

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1. First Name:

First Name:

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2. Last Name:

Last Name:

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3. Street Address (local):

Street Address (local):

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4. City:

City:

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5. State:

State:

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6. Zip:

Zip:

7. Preferred Phone Number:

Preferred Phone Number:

8. Alternate Phone Number:

Alternate Phone Number:

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9. Email Address:

Email Address:

10. Will you be an intern or a student teacher?

Will you be an intern or a student teacher?   Intern (Full year) Student teacher (One semester)

11. Level (Choose One):

Level (Choose One):   Middle School High School Middle and High School (French and Spanish ONLY)

12. Subject Area:

Subject Area:   Biology Chemistry English French History Math Physics Political Science/Political Philosophy (Social Studies) Spanish