Student Teacher Placement Form
(observation/practicum/student teaching/internship/clinical experience)
WELCOME TO THE BERKELEY TOWNSHIP SCHOOL DISTRICT!
Date of placement request *
MM
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DD
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YYYY
University Information
University *
Placement Coordinator *
Placement Coordinator email address *
Placement Coordinator phone number *
Student Information
Student Name *
Mailing Address *
Phone Number *
Alternate Phone Number
Email Address *
Anticipated Date of Graduation *
Date of Background Check (Fingerprinting) *
MM
/
DD
/
YYYY
Application for: *
Please fill out below only if this is an internship. *
Placement Type *
Placement for *
Do you need multiple placement settings? *
Number of hours requested *
Number of hours per teacher/experience *
Preferred Grades *
Required
Schools of Interest *
Required
I verify the accuracy and completeness of the information submitted.
(By typing your name below this form has the same legal force and effect as my handwritten signature)
Preparer's Name *
Preparer's Email *
Submit
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