Student Application for New York City Student Teaching

Form A � page 1 of 2

THE STATE UNIVERSITY OF NEW YORK - URBAN TEACHER EDUCATION CENTER
		
       New York City Department of Education Offices
       65 Court Street, Room 405, Brooklyn, New York 11201
	
	Directions:  Students requesting student teaching in New York City must
       complete this form.  Please return the application package to your campus
       Director of Student Teaching. Please write legibly.





1.	Last Name:  ___________________________	2.  First Name:  ____________________________

3.	Social Security:  __ __ __ /__ __ / __ __ __ __	4.  DOB:  ___________/__________/__________

5.	College / University:  _____________________	6.  Expected Graduation:  Mo.______ Year______

7.	Campus Address:

	Street: ____________________________________________________________________________

     City: ___________________________________  State: __________  Zip Code: _________________

8.	Contact Phone: __ __ __/__ __ __ / __ __ __ __	9.  E-mail: ________________________________

10.	Preferred Method of Contact: 
	
	E-mail ____  Home Phone ____  Cell Phone____  Postal-mail ___

11.	Student Teaching Level:


  Early Childhood ____  Childhood ____  Middle Childhood ____  Adolescence ____            

  Specialty Subject (PreK- 12) ____

12.	Certification Area: ____________________________________________________________________

13.	Student Teaching Term:
	
	Fall _______ Spring _______ of   Year ___________

14.	Date(s), if any, you must be on campus during your student teaching term:

   _____________________________________________________________________________________


Student Application for New York City Student Teaching

Form A � page 2 of 2

15.	Permanent Address: 

	Street: ______________________________________________________________________________
           
     City: _____________________________________   State: ______________Zip Code: _____________
           
     Phone: __ __/__ __ __ / __ __ __ __

16.	Are you applying for housing through SUTEC?
           
     Yes ____  No ____

17.	If you are not applying for housing, where do you plan to reside while student teaching in New York City?  
        
    Provide your address:
          
     Street: ______________________________________________________________________________

	City: ______________________________________  State:_________  Zip Code: _________________
           
     Phone: __ __ __/__ __ __ /__ __ __ ___
										

18.	If you have a preference for a placement site, please mark at least two of the following boroughs:

     Brooklyn ____   Bronx ____   Manhattan ____   Queens ____   Staten Island ____
          
     Reason(s): __________________________________________________________________________

19.	The Director of Student Teaching on your campus is: ________________________________________

     Phone: __ __ __/__ __ __ / __ __ __ ___    	E-mail: ____________________________________

20.	Resume and Personal Essay:

1) SUTEC requires each applicant to submit his/her resume with a short personal essay of no 
more than 500 words explaining his/her reasons for �Choosing Student Teaching in New York City.�
Your essay should focus on one or two reasons.  
                
      Note:  If your campus requires you to submit an education statement, you may submit that 
      statement in lieu of �Choosing Student Teaching in New York City.�




If you have any questions regarding student teaching in a New York City school please contact the 
SUTEC office at 718-935-5515 or send an e-mail to Eli.Seifman@suny.edu.