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Student Teacher/Intern Address and Emergency Notification Information
The information requested below is important to update employee records.
Acknowledgement of Placement Terms *
By agreeing below, you acknowledge that a copy of your 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 *
Your answer
Mailing Address *
Your answer
Unit #
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Primary Phone *
Your answer
Secondary Phone
Your answer
Email Address *
Your answer
College/University Contact Information
Please provide the following information regarding the school you are currently attending.
School Name *
Your answer
Supervising Instructor *
Your answer
Supervising Instructor's Phone Number
Your answer
Supervising Instructor's Email Address
Your answer
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 *
Your answer
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
Your answer
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 *
Your answer
Contact's Relationship *
Your answer
Contact's Primary Phone *
Your answer
Contact's Secondary Phone
Your answer
Alternative Contact's Full Name *
Your answer
Alternative Contact's Relationship *
Your answer
Alternative's Primary Phone *
Your answer
Alternative's Secondary Phone
Your answer
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