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Student Teacher, Service Learning, Observation & Internship Placement Request Information
The information requested below is essential to maintain accurate records. Failure to provide complete and accurate information may result in a delay to your placement
Acknowledgement of Placement Terms *
By agreeing below, you acknowledge that a copy of your Department of Public Safety Level One IVP Fingerprint Clearance Card and Driver License must be received by our office prior to placement in a classroom. The placement process may take 1-2 weeks.
Personal Information
Today's Date *
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Full Name *
Mailing Address *
Unit #
City *
State *
Zip Code *
Primary Phone *
Secondary Phone
Email Address *
College/University Contact Information
Please provide the following information regarding the school you are currently attending.
School Name *
Supervising Instructor *
Supervising Instructor's Phone Number
Supervising Instructor's Email Address
Requesting Placement for: *
Please note that if you are looking for OT, PT, Speech or Psychology, you must use the Related Services Form. (Find the link on the Student Teacher/Intern Page)
School Year *
Semester *
Total Hours Needed *
What date would you like your placement to begin? *
Please remember that placements can take up to two weeks from the time we receive your ID and Fingerprint Clearance Card.
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Content Area/Grade Level Preference
Preferred School Site *
Please select the site your site preference.
Emergency Contact Information
If you should become seriously ill or injured at work, we need to be able to contact a family member or friend who would be able to help. Please provide the name and contact information for two people who could assist you or who might be able to provide information that would be helpful to the medical providers.
Contact's Full Name *
Contact's Relationship *
Contact's Primary Phone *
Contact's Secondary Phone
Alternative Contact's Full Name *
Alternative Contact's Relationship *
Alternative Contact's Primary Phone *
Alternative's Secondary Phone
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