LEGAL NAME __________________________________________ 
                          (last)                                (first)                             (mi)

LOCAL ADDRESS ________________________________________ LOCAL PHONE ___________

__________________________________________________________________________________
                          (city)                                                       (state)                                   (zip)

CERTIFICATION AREA(S) ____________________________ 

ASSIGNMENT ____________________________________________________________________
                                      teacher                                    school                                        grade/subject

BEGIN DATE _____________    END DATE ____________  HOURS IN CLASSROOM _______

I certify that the information provided by me is accurate.

_________________________________________________________________________________
Student Signature                                                                                                     Date

    This form must be completed and submitted to the Education Assistance Center before a final
    grade will be given.  The student should keep a copy for his/her Professional Portfolio
_________________________________________________________________________________

                                                    Cooperating Teacher's Section
Student's involvement in the classroom: (yes, no, n/a, and/or comments)
        Tutored individuals _____________________________________________________________
        Assisted large group activities _____________________________________________________
        Assisted students in work/study periods _____________________________________________
        Led small group activities ________________________________________________________
        Prepared instructional materials ____________________________________________________
        Planned and taught one literature-based lesson ________________________________________
        Other _______________________________________________________________________

Brief statement as to the student's dependability, effort, attitude, initiative, cooperation, interpersonal
relations, etc.:

________________________________________________________________________________

Would you recommend the consideration of this student for Professional Teacher Education?
Yes __________     No __________   Undecided ____________

________________________________________________________________________________
              (school)                                       (supervising teacher signature)                            (date)