Cooperating Teacher Information Form
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1
2ALICE LLOYD COLLEGE
Cooperating Teacher Information Form
Name
Date
Home Address _____________________________ Home Phone_____________
Social Security Number__________________________ E-mail_______________
School
County
Grade level/subject___________________________________________________
In order to comply with Kentucky State Board of Education guidelines, please provide the
following information for our files.
1.
Kind of
Certificate
Expiration
Subject/Area
Certificate
Number
Date
of certification
2. Master's Degree of Fifth Year Program:
College Attended
Area of Study
Year Work Completed
3. Total number of years teaching experience:
(Must have a minimum of 4 years to supervise student teachers)
4. Number of years taught at current school:
5.
Have you ever received KTIP training?
yes
no
Date
Signature of Cooperating Teacher
*Mandatory for the Education Professional Standards Board
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