Application For Admission To Teacher Education

Complete this form and use the submit button at the bottom for submission by November 30th of your sophomore year.

Name: Name: First Last
EMU ID#:
Licensure Areas (list all):
Advisors (list all):
According to my 4 year plan, I plan to enroll in professional block courses in the following semester(s):

Primary & Elementary Ed., PreK-3 and PreK-6
Curriculum Block (ED331-333)

According to my 4 year plan, I plan to enroll in professional block courses in the following semester(s):

Primary & Elementary Ed., PreK-3 and PreK-6
Curriculum Block (ED331-333) Spring 2024 Spring 2025 Spring 2026 Spring 2027
According to my 4 year plan, I plan to enroll in professional block courses in the following semester(s):

Primary & Elementary Ed., PreK-3 and PreK-6
Literacy Block (ED341-343)

According to my 4 year plan, I plan to enroll in professional block courses in the following semester(s):

Primary & Elementary Ed., PreK-3 and PreK-6
Literacy Block (ED341-343) Fall 2024 Fall 2025 Fall 2026 Fall 2027
According to my 4 year plan, I plan to enroll in professional block courses in the following semester(s):

All Grade Education, PreK-12
General Methods (ED351) and content area courses

According to my 4 year plan, I plan to enroll in professional block courses in the following semester(s):

All Grade Education, PreK-12
General Methods (ED351) and content area courses Fall 2024 Fall 2025 Fall 2026 Fall 2027
According to my 4 year plan, I plan to enroll in professional block courses in the following semester(s):

Secondary Education, 6-12
Middle & Secondary Curriculum Block (ED 351, 361, 385)

According to my 4 year plan, I plan to enroll in professional block courses in the following semester(s):

Secondary Education, 6-12
Middle & Secondary Curriculum Block (ED 351, 361, 385) Fall 2024 Fall 2025 Fall 2026 Fall 2027
According to my 4 year plan, I plan to be on cross cultural at the following time:
(please select both the term and year)

According to my 4 year plan, I plan to be on cross cultural at the following time:
(please select both the term and year) Fall Spring Summer 2024 2025 2026 2027 Other Other
According to my 4 year plan, I plan to student teach at the following time:
(please select both the term and year)

According to my 4 year plan, I plan to student teach at the following time:
(please select both the term and year) Fall Spring 2024 2025 2026 2027 Other Other
According to my 4 year plan, I plan to graduate at the following time:
(please select both the term and year)

According to my 4 year plan, I plan to graduate at the following time:
(please select both the term and year) December April/May June August 2024 2025 2026 2027 2028 Other Other
Sign below to verify the following:

1) I have read the admission requirements for Teacher Education and Student Teaching found in the teacher education handbook (www.emu.edu/education/program-procedures/).

2) I have read and acknowledge understanding of the sections related to conditions for licensure in Virginia as stated in Virginia's Licensure Regulations for School Personnel.
*Pertinent sections of the Licensure Regulations for School Personnel can be found at http://www.emu.edu/education/education-forms/.*

3) I waive my right to view the information provided by my references.

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Full Name
Date: Date: / MM / DD YYYY
Have you ever been convicted of, or entered a plea of guilty or no contest to, a felony? (If yes, please send a letter of explanation and a copy of the court documents indicating judgement and disposition of the case from the court to education@emu.edu.)

Have you ever been convicted of, or entered a plea of guilty or no contest to, a felony? (If yes, please send a letter of explanation and a copy of the court documents indicating judgement and disposition of the case from the court to education@emu.edu.) Yes No
Have you ever been convicted of, or entered a plea of guilty or no contest to, a criminal offense in another country? (If yes, please send a letter of explanation and a copy of the court documents indicating judgement and disposition of the case from the court to education@emu.edu.)

Have you ever been convicted of, or entered a plea of guilty or no contest to, a criminal offense in another country? (If yes, please send a letter of explanation and a copy of the court documents indicating judgement and disposition of the case from the court to education@emu.edu.) Yes No
Have you ever been convicted of, or entered a plea of guilty or no contest to, a misdemeanor involving a child (minor) or a student? (If yes, please send a letter of explanation and a copy of the court documents indicating judgement and disposition of the case from the court to education@emu.edu.)

Have you ever been convicted of, or entered a plea of guilty or no contest to, a misdemeanor involving a child (minor) or a student? (If yes, please send a letter of explanation and a copy of the court documents indicating judgement and disposition of the case from the court to education@emu.edu.) Yes No
Have you ever been convicted of, or entered a plea of guilty or no contest to, a misdemeanor involving drugs (not alcohol)? (If yes, please send a letter of explanation and a copy of the court documents indicating judgement and disposition of the case from the court to education@emu.edu.)

Have you ever been convicted of, or entered a plea of guilty or no contest to, a misdemeanor involving drugs (not alcohol)? (If yes, please send a letter of explanation and a copy of the court documents indicating judgement and disposition of the case from the court to education@emu.edu.) Yes No
Have you ever been the subject of a founded complaint of child abuse or neglect by a child protection agency? (If yes, please send a letter giving full details and official documentation of the action taken to education@emu.edu.)

Have you ever been the subject of a founded complaint of child abuse or neglect by a child protection agency? (If yes, please send a letter giving full details and official documentation of the action taken to education@emu.edu.) Yes No
Have you ever had a teaching, administrator, pupil personnel services, or other education-related certificate or license revoked, suspended, invalidated, cancelled, or denied by another state, territory, or country; surrendered such a license or the right to apply for a license; or had any other adverse action taken against such a license? Please note: This includes a reprimand, warning, or reproval and any order denying the right to apply or reapply for a license. (If yes, please send a letter giving full details and official documentation of the action taken to education@emu.edu.)

Have you ever had a teaching, administrator, pupil personnel services, or other education-related certificate or license revoked, suspended, invalidated, cancelled, or denied by another state, territory, or country; surrendered such a license or the right to apply for a license; or had any other adverse action taken against such a license? Please note: This includes a reprimand, warning, or reproval and any order denying the right to apply or reapply for a license. (If yes, please send a letter giving full details and official documentation of the action taken to education@emu.edu.) Yes No
Are you currently the subject of any review, inquiry, investigation, or appeal of alleged misconduct that could warrant discipline or termination by a school division or other education-related employer or an adverse action against a teaching, administrator, pupil personnel services, or other education-related license or certificate? Please note: This includes any open investigation by or pending proceeding with a child protection agency and any pending criminal charges. (If yes, please send a letter giving full details and official documentation available regarding the matter to education@emu.edu.)

Are you currently the subject of any review, inquiry, investigation, or appeal of alleged misconduct that could warrant discipline or termination by a school division or other education-related employer or an adverse action against a teaching, administrator, pupil personnel services, or other education-related license or certificate? Please note: This includes any open investigation by or pending proceeding with a child protection agency and any pending criminal charges. (If yes, please send a letter giving full details and official documentation available regarding the matter to education@emu.edu.) Yes No
Have you ever left any education- or school-related employment, voluntary or involuntarily, under any of the following circumstances: (1) while the subject of a review, inquiry, investigation, or appeal of alleged misconduct; (2) when you have reason to believe a review, inquiry, investigation or appeal of alleged misconduct was under way or imminent; or (3) while any administrative or judicial proceeding involving an allegation of misconduct was pending, eligible for appeal, or under appeal? Please note: This includes any open investigation by or pending proceeding with a child protection agency and any pending criminal charges. (If yes, please send a letter giving full details and official documentation available regarding the matter to education@emu.edu.)

Have you ever left any education- or school-related employment, voluntary or involuntarily, under any of the following circumstances: (1) while the subject of a review, inquiry, investigation, or appeal of alleged misconduct; (2) when you have reason to believe a review, inquiry, investigation or appeal of alleged misconduct was under way or imminent; or (3) while any administrative or judicial proceeding involving an allegation of misconduct was pending, eligible for appeal, or under appeal? Please note: This includes any open investigation by or pending proceeding with a child protection agency and any pending criminal charges. (If yes, please send a letter giving full details and official documentation available regarding the matter to education@emu.edu.) Yes No
If you answered "yes" to any of the above questions, you will need to meet with the director of undergraduate teacher education to discuss how this affects your program and ability to secure a teaching license.

BY MY SIGNATURE, I CERTIFY THAT THE INFORMATION ON THIS FORM IS ACCURATE AND COMPLETE. I UNDERSTAND THAT MISREPRESENTATION MAY RESULT IN THE DENIAL, REVOCATION, CANCELLATION, OR SUSPENSION OF A VIRGINIA LICENSE.

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Date: Date: / MM / DD YYYY