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Student Teacher Enrollment Form
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School District
Please type in the name of the district where you are doing your student teaching.
Full Name
*
First
Last
Home Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Best Contact Phone Number
*
Best Email Address
*
District Email Address
Current Position
*
Campus / Department Assignment
Student Teacher Membership Agreement
By signing below, I hereby agree to become a member of the United Educators Association as a Student Teacher. I understand my dues will be free for the current School Year. When you obtain your first position, this membership will not automatically carry over. You will need to complete a new enrollment form as a New UEA Member.
Signature
*
Clear Signature
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