Cooperating Teacher Profile

Thank you for taking the time to complete this form.  Information collected will be kept as part of our permanent records required for accreditation.  In the future, we will ask you to update this information once a teacher candidate has been placed in your educational setting.  We appreciate your willingness to work with our teacher candidates and your continued support of our program. If you have difficulties completing this form or have questions please contact Shane Kirchner at 620-242-0544 or kirchnes@mcpherson.edu.

PLEASE DO NOT HIT THE ENTER BUTTON UNTIL YOU ARE READY TO SUBMIT THE FORM. You may use the tab to go from field to field.

Personal Information

Last Name 

First Name 

Middle Initial Gender Ethnicity

Contact Information

Mailing Address

City   State Zip

Phone Fax E-mail

Academic Degree(s)

Degree Area  Institution City State Mo/Yr

Certification/Licensure

Description Date Issued Date Expires

Instructional Assignments (Fall 2002 - Spring 2007)

Assignment  Grade School District   State From  To

Related Educational Assignments (Fall 2002- Spring 2007)

Description Location From To

Professional Memberships and Community Service

Organization  Affiliation From To

Honors, Presentations, and Publications (Fall 2002- Spring 2007)

Title  Location Date