Step 1 of 2 50% JAC Card Number* Name First Last I am pursuing a* 4 Year Licensure Program 5 Year licensure Program (Bachelor's and MAT) Graduate Program (MAT/MEd) Is this your first year at JMU Yes No Were you accepted as a transfer student?* Yes No Graduate ProgramsEarly / Primary (PreK-3)Secondary (6-12)Special Education (K-12)Early Childhood Special Education (Ages 0-5)Art (PreK-12)Music (PreK-12)5 Year Education ProgramsEarly / Primary (PreK-3)Elementary (PreK-6)Middle (6-8)Secondary (6-12)Special Education (K-12)Inclusive Early Childhood (PreK3, ECSE Ages 0-5)Physical Health Education (PreK-12)4 Year Education ProgramsEarly / Primary (PreK-3)Elementary (PreK-6)Middle (6-8)Secondary (6-12)Special Education (K-12)Inclusive Early Childhood (PreK3, ECSE Ages 0-5)Art (PreK-12)Music (PreK-12)Theater (PreK-12)Dance (PreK-12)Foreign Language (PreK-12)Content AreaChoose 2 English Math Science Social Studies Content AreaChoose 1 (or 2) English Math Science Social Studies Secondary Biology Chemistry Earth Science English Math History and Social Sciences Physics Special EducationChoose one or both Adapted General Curriculum Foreign Language French Spanish German Italian FelonyHave you ever been convicted of, or entered a plea of guilty or no contest to, a felony anywhere in the United States or a criminal offense in another country or a U.S. territory?* Yes No Have you ever been convicted of, or entered a plea of guilty or no contest to, a misdemeanor involving children (minor) or a student?* Yes No Have you ever been convicted of, or entered a plea of guilty or no contest to, a misdemeanor involving drugs (not alcohol)?* Yes No Please attach a letter giving full details and any official documentation available regarding the matter.Have you ever been the subject of a founded complaint of child abuse or neglect by a child protection agency?* Yes No Have you ever had an education related certificate or license OR been employed by a school?* 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 such 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. 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. Yes No Have you ever left any education- or school-related employment, voluntarily 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 had 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. Yes No Full Disclosure Statement School divisions routinely require a background check prior to student teaching. Professional behaviors are expected of all candidates throughout the program. Convictions for criminal offenses or charges pending against you may result in schools refusing to make a placement for practicum or student teaching. There may also be serious consequences when being considered for a license to teach in Virginia and in other states. Therefore, you are required to inform the Director of the Education Support Center in writing of any conviction or pending charges for a misdemeanor / felony, violation of a criminal drug law, an alcohol beverage control law or law that governs driving while intoxicated. Notification must be made no later than five calendar days after such charge or conviction. Full Disclosure Text I have read and will abide by the full disclosure statement.Privacy Policy I understand that my contact information (email, address, and/or phone) may be shared with external contacts (e.g. PreK-12 administrators, teachers, departments of education) for field placement and/or licensure. Privacy Policy* I agree to the privacy policy* Δ
