Teacher Candidate (Student Teacher) Personal Data Form The information you provide in this personal data form will be shared with your cooperating teacher as well as your university supervisor and/or the Director of Student Teaching at the beginning of your student teaching internship placement. The information is used to support you in successfully completing your student teaching internship. Question Title * 1. Student Teacher's Name (First & Last) Question Title * 2. In what semester are you student teaching? Fall 2015 Spring 2016 Fall 2016 Spring 2017 Fall 2017 Spring 2018 Fall 2018 Spring 2019 Fall 2019 Spring 2020 Fall 2020 Spring 2021 Fall 2021 Spring 2022 Fall 2022 Spring 2023 Fall 2023 Spring 2024 Question Title * 3. Please provide the following contact information. Provide a local address and "best to reach me" phone number. Address: * Address 2: City/Town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * Email Address: * Phone Number: * Question Title * 4. Emergency Contact : Provide information about the person you wish to be contacted on your behalf, in the event of an emergency. Name: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Phone Number: Question Title * 5. Select your Regent University program of study Early and Primary Education, PreK-3 - undergraduate Elementary Education, PreK-6 - undergraduate Elementary Education, PreK-6 - graduate Secondary Education, English Secondary Education, Math Secondary Education, History and Social Science Next