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Student I.D.Student First NameStudent Last NameSt PhoneStudent CI EmailCompleted PracticumCertificate of Clearance/OtherMandated Reporter TrainingDES Last NameDES First NameDES EmailGrade LevelType of placement (Public, Private, Other)Private or Other - Supervisor DegreeSchoolSchool AddressDistrictDiverse Student Population?
Social/Emotional Counseling Activities?		College/Career Counseling Activities?Academic Counseling Activities?SemesterFieldwork Course SectionCI SupervisorSupervisor EmailPlease let us know about where you will be residing during your fieldwork, so that we can try to minimize your commuting distance.School sites where family members are employedComments
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