Placement Request form
Materials:
1. A separate Student Placement Request Form (SPRF) is required for each request.
2. Indicate type of placement.
3. Student placement request form must be completed, signed, and submitted by the student’s Learning Institution (college or university) - student placement office or student placement coordinator. How to submit the form? Submit the form electronically as an attachment by email to HCS-FIELDPLACEMENT@hampton.k12.va.us or Fax to Hampton City Schools 1 Franklin Street, Hampton, VA 23669 - Fax# 757-727-2298
(Request received directly from a student will not be processed)
4. Please allow 10 business days from receipt of this form in our office for placement confirmation.
5. The students are required to contact the Cooperative/supervising teacher, counselor or prior to start date.
Email address *
University Information
Placement type *
Name of College/University *
Your answer
Placement Office Representative Name *
Your answer
Placement Office Representative Title *
Your answer
Placement Office Representative Email *
Your answer
Placement Office Representative Phone *
Your answer
Course Title
If applicable
Your answer
Professor/Instructor Name
If applicable
Your answer
Professor/Instructor Phone
If applicable
Your answer
Professor/Instructor Email
If applicable
Your answer
Student Information
Student Name *
Your answer
Student Email *
Your answer
Student Phone *
Your answer
Student Estimated Graduation Date *
Your answer
Student Classification *
Request Info
Level *
If Elementary, grade?
If Secondary, content area?
Start Date? *
ex: 9/8/17, not Sept 8 or 9/8
MM
/
DD
/
YYYY
End Date? *
ex: 12/8/17, not Dec 8 or 12/8
MM
/
DD
/
YYYY
Total time in Hours or Weeks? *
Based on your response, how many? *
Your answer
School Preference #1
Please note: Request does not equate to placement.
Your answer
School Preference #2
Please note: Request does not equate to placement.
Your answer
Explanation of School Preferences or other special requests
Please note: Request does not equate to placement.
Your answer
Relatives in the requested school/s?
Please note: Request does not equate to placement.
Fingerprinting might be required based type of request and number of hours requested. After confirmation of placement with Hampton City Schools the Learning Institution will be given additional information regarding fingerprinting and background check. Students requesting less than 40 hours will not require fingerprinting at this time. *
Required
Your submission of this form will serve as an electronic signature. *
Required
Confidentiality is a legal issue and agree not to discuss experiences in a manner that will allow identification of any student or individuals associated with Hampton City Schools. I will contact the assigned mentor/cooperating teacher prior to my start date to arrange a mutually convenient schedule. *
Required
Questions/Comments
Your answer
A copy of your responses will be emailed to the address you provided.
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