PRESERVICE PLACEMENT REQUEST FORM

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If you wish to request placement in Fremont County School District #25 to complete your preservice requirements (i.e. observation hours, practicum hours, internships, or a student teacher residency), please complete this form.

Your request will be reviewed and determination of placement will be forthcoming. Please do not contact any school personnel directly until your placement has been approved.

Please have your University Placement Coordinator contact FCSD#25 with University Placement request verification to:

Lindy Nielsen (lnielsen@fremont25.org).

Your request cannot be processed without detailed information. Please avoid responding with "question marks", "undefined", "don't know", "NA", etc. Work with your university to provide complete information.

*A Request Form is required for EACH Preservice Request

Email *

Record my email address with my response

Legal First Name: *

Legal Last Name:
*

Last 4 SSN:
*

Phone Number: (area code + number)
*

FCSD#25 Employee ID#: (if applicable)

FCSD#25 Employment Position: (if applicable) Please specify whether you are in a classified, certified or substitute position.

FCSD#25 Employment Location(s): (if applicable) Enter the building you currently work in.

Were you hired in FCSD#25 on a transitional license through PTSB?

Yes

Clear selection

Placement Time Period (When will you start and finish):
*

Types of Pre-service Needed: *

Anticipated Date of Preservice Completion: *

YYYY

Total Number of Hours and/or Weeks Required for Preservice: (Please estimate if you do not know exact number of hours/weeks) *

Grade Level Requested for Preservice *

Preservice Area of Concentration: *

Do you currently hold a State of Wyoming (PTSB) substitute permit? *

Yes

Not Applicable

Do you currently hold a State of Wyoming (PTSB) internship permit?*
*

Yes

Not Applicable

If you have children and/or family members at FCSD#25, please list name(s) and location(s) below or write none.
*

Have you ever been convicted of a misdemeanor or felony other than a minor traffic offense?

**NOTE: Affirmative response of a misdemeanor or felony conviction(s) must be fully explained in a separate signed statement submitted to FCSD#25 ATTN: Lindy Nielsen, HR Director, 121 N. 5th St. W., Riverton, WY. 82501 OR scanned and email to lnielsen@fremont25.org . Please indicate the date(s) of offense(s), nature of offense(s), court action(s) and a personal assessment (What have you learned from this experience?)

University Attending: *

University Program Coordinator: *

University Program Coordinator Email: *

University Program Coordinator Phone Number: (area code + number)
*

School Preference for Preservice Assignment:
*

Mentor Preference for Preservice Assignment:

Please add any additional comments, questions or specificity that has not been included in this form.

FOR SOCIAL WORK AND SCHOOL COUNSELING ONLY:

Please list the credentials your site supervisor and/or mentor must have? Briefly describe their responsibilities.

Your answer