First Name *

Last Name *

G-Number *

Date of Birth *
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Street Address *

City *

Zip Code *

Phone Number *

Email Address (best to reach you at): *

Email Address (best to reach you at): (Confirmation) *

GVSU Email Address *

GVSU Email Address (Confirmation) *

Year Graduated (Bachelor's) *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Elementary candidates must register for and successfully complete two prerequisite courses (HPE 267 and EDT 619) prior to their intended cohort start semester in May. Courses must be completed with a B- or higher to move forward in the program. Please identify the following:

When did you/will you complete the prerequisite HPE 267? Please list semester and year (i.e. Fall, 2023): *

When did you/will you complete the prerequisite EDT 619? Please list semester and year (i.e. Fall, 2023): *

Grand Valley State University's College of Education and Community Innovation has strict requirements for students pursuing teacher certification at our university. Students who have certain civil infractions (excluding speeding tickets), certain misdemeanors, multiple misdemeanors, or felony(s) may be denied admission to the College of Education and Community Innovation. If admission is granted, a field placement might not be found due to district policies and procedures. If a student is recommended to the Michigan Department of Education for teacher certification, the conviction could have an adverse effect on being granted a teaching certificate. Be advised, if a teaching certificate is granted with convictions or infractions, it does not guarantee PK-12 employment.

THE BELOW QUESTIONS DO NOT PERTAIN TO EXPUNGED AND/OR DEFERRED CHARGES

Have you ever been convicted of a felony or misdemeanor? *
- Select Option No Yes

Which have you been convicted for? *
Felony
Misdemeanor

Do you have charges pending? *
- Select Option No Yes

Have you ever had a teaching/administrator certificate or school counseling/psychologist license denied, revoked, or suspended? *
- Select Option No Yes

What was the specific offense? *

What was the date of the conviction(s)? *

What was the conviction(s)? *

In what city and state did the offense(s) occur? *

What was the case number(s)? *

Please obtain and attach photocopies of court documentation (i.e., register of action, summary or "Judgement of Sentence") from the court proceedings and any related background information that you consider important.

If you have any felony or misdemeanor charges, and it is a NEW charge since you turned in your last application, please attach pertinent information regarding the NEW issue to this application. If you turned in this information previously, we do not need to have the paperwork again.

If charged with a misdemeanor and/or felony after submission of this application, I will notify immediately the Office of Certification and Accreditation at (616)331-6650 and will provide copies of court documents. 

If you have questions about convictions and reporting this information, please contact the Office of Certification and Accreditation at [email protected].

Please sign below.

Pursuant to federal law, the Family Educational Rights and Privacy Act of 1974, as amended, (FERPA) requires, subject to specific exceptions, Grand Valley State University to have written permission from its students before releasing any information from a student’s educational record.

The academic requirement of Grand Valley State University’s College of Education and Community Innovation (CECI) mandates that each of its students complete teacher assisting and student teaching field practicum. In order for field placements to be made by CECI, it must be permitted to disclose students’ records to school districts, which are prospective placement sites for the students to complete their practicum requirements. Student records include all educational records maintained by the University on behalf of the student. Further, post students’ graduation from Grand Valley State University, we are frequently asked to provide employment recommendations. In order for these recommendations to be made by CECI, we also need to have permission granted to disclose student records maintained by the University on behalf of the student.

In recognition of the above, applications for admission into CECI must include this signed consent to release education records.

Please read the following statements. By signing below you are agreeing to authorize a representative of Grand Valley State University permission to release pertinent records regarding your education history at our institution:

• I authorize a designated representative of Grand Valley State University to release my educational records to school districts in which I may be placed for either teacher assisting or student teaching. This consent does not require the release of such educational records, if, in its sole discretion, the University deems it unnecessary to do so, nor does the release of educational records guarantee my placement at any school district.
• I authorize a designated representative of Grand Valley State University to release my educational records to school districts in which I may be an applicant for a paid position, including but not limited to the position of teacher. This consent does not require the release of such educational records, if, in its sole discretion, the University deems it unnecessary to do so for the purpose of employment outside of the University.

I acknowledge that I may review my educational records maintained by the College of Education and Community Innovation provided I submit my written request to the Dean of CECI three (3) business days in advance and that such review will take place between 8:00 a.m. and 5:00 p.m., Monday through Friday on days Grand Valley State University is open for business. The University’s policy on the Family Educational Rights and Privacy Act of 1974, as amended, as stated in Section 209 of the Student Code shall govern all other aspects of my educational records and Live Scan results.

Grand Valley State University, its Board of Trustees, officers, employees, agents are hereby released from legal responsibility or liability for the release of such information and records as authorized by this consent form.

• I have read the above consent information and give willful consent of all its terms and conditions.
• I agree to the release of my educational records under the above detailed circumstances.
• I understand that placements, including school location and grade level, will be made in terms of programmatic needs and design, supervisory load, and the availability of placement situations within the schools within the placement radius.
• I am willing to accept the placement assignment as determined by College of Education and Community Innovation and further understand that particular interest areas and grade levels will not necessarily be accommodated.
• I understand that transportation to and from my placement assignment is my responsibility.
• I agree to report changes of name, address, telephone number and e-mail address immediately to the College of Education and Community Innovation.
• I agree to notify the College of Education and Community Innovation if I receive a placement where a relative is employed or attending school.
• I certify that the answers given in my application are complete and accurate. Failure to provide accurate information or concealment or misrepresentation of any information may result in denial of admission, field placements, recommendation for teacher certification, or recommendation for additional endorsements.

I have read all the information above and have completed this application to the best of my ability.

Today's Date *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Verification of Experience Form
Please upload a file with the extension .doc, .pdf, .docx, .jpeg, .jpg, or .png with a maximum size of 1 MB (1024 KB)

Educator Resume
Please upload a file with the extension .doc, .pdf, .docx, .jpeg, .jpg, or .png with a maximum size of 1 MB (1024 KB)