Application for Student Teaching/MAT Internship (without employment)   (Form 1 of 4)

Please select the correct application
Student Teaching
MAT Internship(without employment)
Semester/Year in which you plan to student teach :  / 
Last Name :   First Name :  
Eagle ID#:      GSU Email Address only:
Preferred name to be used is:

Indicate your degree status: B.S.Ed., MAT, Non-Degree certification


Using this list, indicate your area of certification: Art, Early Childhood, Special Education, Foreign Language, Health/PE, Middle Grades, Music, Secondary, Techology or other.


Content area(s) of concentration for Math, Science, English, Language Arts, Social Studies or other.


Permanent home mailing address (Street, City, State, Zip):

Telephone number of permanent home address:   Area Code Number

University PO Box:


Address where you will reside during student teaching (Street, City, State, Zip):

University telephone number:   Area Code Number

Cell phone number include area code:

All Georgia Southern University student teachers/interns will be placed in one geographical location: Georgia Southern University 60 mile radius area. The GSU 60 mile radius area is the primary location for placements. This area includes these systems: Appling, Bryan, Bulloch, Burke, Candler, Chatham, Effingham, Emanuel, Evans, Jefferson, Jenkins, Liberty, Long, Montgomery, Screven, Tattnall, Toombs, Vidalia City and Wayne.

Do you have relatives as STUDENTS in schools within the 60 mile radius for which you are applying to student teach/internship?
Yes   No  N/A 
If "Yes," please name school & system in which these relatives are enrolled and relationship to student teacher/interns: i.e. sister, nephew, etc.
School/System Relationship
School/System Relationship

Do you have relatives as EMPLOYEES in schools within the 60 mile radius? Yes   No  N/A 
If "Yes," please name school & system in which these relatives are employed and relationship to student teacher: i.e. father, aunt, etc.
School/System Relationship
School/System Relationship
School/System Relationship

University and Schools attended:

Names of college/universities other than Ga. Southern you attended:
School City State
School City State
School City State

Names of high schools you attended:
School City State
School City State
School City State

Names of middle schools you attended:
School City State
School City State
School City State

Names of elementary schools you attended:
School City State
School City State
School City State

Extenuating circumstances you would like to share concerning your student teaching/internship placement. Program coordinators will take this into consideration, but you are not guaranteed a placement based on this information.
(This is an expanding field so do not feel limited by the space shown.)

List the field experience courses in your teacher prepration program (school, grade level and subject, university supervisor). Begin with PPB assignment in sequential order through current semester.

GSU Course
Name of School
Grade Level
Subjects Observed/Taught
University Supervisor


Criminal Background Check

You must complete a criminal background check as part of the student teaching application. To obtain additional information about the criminal backgrouond check, you may visit our website:   http://coe.georgiasouthern.edu/oute/    or contact The Office of Undergraduate Teacher Education.

By completing and submitting this form to the Office of Undergraduate Teacher Education, I confirm that I understand it is my responsibility to immediately report any change in my placement status to the Director of Field Experiences. Additionally, I understand that eligibility for student teaching/internship is dependent upon meeting all admission criteria described in the current GEORGIA SOUTHERN UNIVERSITY GENERAL CATALOG.

Have you passed GACE I?          Yes           No

Have you passed GACE II?          Yes           No