Student Teacher Placement Form
(observation/practicum/student teaching/internship/clinical experience)
Email *
WELCOME TO THE HAMILTON TOWNSHIP SCHOOL DISTRICT!
Date of placement request
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DD
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UNIVERSITY INFORMATION
Name of University
Placement Coordinator
Placement Coordinator Email
Placement Coordinator Phone Number
STUDENT INFORMATION
Student Last Name
Student First Name
Mailing Address
Student Phone Number
Student Email
Anticipated Date of Graduation
MM
/
DD
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YYYY
Date of Background Check/Fingerprinting
MM
/
DD
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YYYY
Application for:
Please fill out only for an internship
Placement for
Clear selection
Do you need multiple placement settings?
Clear selection
Number of hours requested:
Number of hours per teacher / experience
Preferred Grades
Clear selection
Schools of interest
Clear selection
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
A copy of your responses will be emailed to the address you provided.
Submit
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