Speech Pathology STAR Form worksheet
This worksheet is to provide you with information requested on the STAR Form.

Grade level preference:

1st Preference:

2nd Preference:

3rd Preference:


First School Preference
Building
District

Second School Preference
Building
District

Third School Preference
Building
District


First Name:

Middle Name:

Maiden Name:

Last Name:

Do you have transportation available? Yes/No

If you have school age children, please give their grade level(s) and the school(s) they attend:

Are you or your family members related to or are friends with any employee(s) of the district(s) in which you have applied to student teach? Yes/No

If you have answered 'Yes' to the previous question, please explain.

In case of emergency while student teaching, notify:

Name:

Address:

City, St., Zip:

Phone:

CONTINUE