Teacher Educator Availability

Name:

SSN# (last 4 only):

WKU ID#:800-

Home Address:

City:

State:

Zip:

Phone (H):

Phone (W or cell):

Email:

Availability:

I will work with interns during the 2013-14 school year.
(specify the number)

I will be unable to work with interns during the 2013-14 school year.

Have you retired from teaching?
Yes No

If yes, what year?

I would prefer assignments in the following district/area:

   1.
   2.
   3.

Preferred Level/(s):
      Primary
      Middle
      High School

If Middle/High School, please specify preferred content area(s):
Content Area(s):

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Kentucky Teacher Internship Program
Western Kentucky University
ktip@wku.edu
Phone 270.745.5991 or Fax 270.745.6279