1.Name: Telephone: Email:

2. Home Address:

                                               Street            City            State             Zip            County

3. Social Security Number :ID Number

4. Application for : Junior Field Experience Senior Field Experience Fall Spring Summer

5. High School Attended : 6. Status: Full Time Student Part Time Student

7. Kean University Major : Minor Graduation

8.To be completed if a college degree has been conferred:

            College or University Date of Graduation

            Major Minor

            Now Seeking Certification in

            Now Seeking Master's degree in

9. Activities: College

            Community

10. Work Experience:

11.Junior Field Experience: District

            School Grade or Subject

12. Other School Observation, Tutoring, or Teaching Experience

13.Special Honors:

14. Hobbies, Travel, Special Interests or Abilities:

15. Substitute Certification: Yes No County

16. Emergency Phone: Contact Person and Relationship: