Southern Illinois University Carbondale

Department of Health Education and Recreation

 

DRIVER EDUCATION STUDENT TEACHING EXPERIENCE APPLICATION

 

I.          PERSONAL INFORMATION

 

            A.        NAME: (PRINT) ______________________ DATE:  ______________________

            B.        STUDENT ID: ________________ADVISOR: ___________________________

            C.        LOCAL ADDRESS:  ________________________________________________

                                                                                 (Street), P. O. Box, etc.)

            D.        LOCAL TELEPHONE: ___________________________ or _________________

                                                               (Area Code)           (Number)                    (Extension)

            E.         UNIVERSITY SUPERVISOR: _________________________________________

            F.         SEMESTER/SUMMER DRIVING STUDENT TEACHING YEAR: ___________

 

II.        SCHOOL/MASTER TEACHER INFORMATION: Name and Title of Immediate Supervisor

 

            A.        NAME: ___________________________ TITLE __________________________

            B.        COMPANY: _______________________________________________________

            C.        ADDRESS: ________________________________________________________

                                                                        (Street, P. O. Box, etc.)

            D.        TELEPHONE: ____________________________ or _______________________

                                                (Area Code)                (Number)                         (Extension)

 

III.       ACADEMIC ELIGIBILITY FOR DRIVER EDUCATION STUDENT TEACHING

 

A.                Student has completed at least 60 hours of undergraduate course work with a grade point average of 2.00 or higher, or by consent of the instructor.

a.       Overall GPA: _____________

            B.        Student has completed HED 302s Driving Task Analysis or equivalent with a grade of C or better

                        HED 302s: _____________________

 

IV.       RECEIVED EVIDENCE OF SATISFACTORY DRIVING RECORD FROM STATE OF ILLINOIS DEPARTMENT OF TRANSPORTATION: ______________________________

 

V.        ELIGIBLE TO BECOME A CERTIFIED TEACHER IN ILLINOIS

 

APPROVED              _______________

POSTPONED             _______________

DENIED                     _______________

 

I have read and understand the attached Statement of purpose, work experience, and required reports relating to the driver education teaching experience to which this application relates, as well as the attached agreement between SIUC and ______________________, where I will be placed for my driver education teaching experience. By signing this Driver Education Teaching Experience Application, I agree to comply with the portion of these documents that relate to me.

 

 

 

 

Print Name                                          Date		Signature

 

 

 

MAIL THIS FORM TO:        Dale O. Ritzel

Department of Health Education and Recreation

Southern Illinois University Carbondale

Carbondale IL 62901-6731

(618) 453-2777

                                                safety@siu.edu