T8 field experience 351.pdf - CLINICAL FIELD EXPERIENCE...

CLINICAL FIELD EXPERIENCE VERIFICATION FORM
CANDIDATE NAME STUDENTNUMBER
PROGRAM :
COURSE:
START DATE: ENDDATE:
PRACTICUM/FIELD EXPERIENCE FACILITY NAME:
SCHOOL STATE:
MENTOR NAME:
TOTAL PRACTICUM/FIELD EXPERIENCE HOURS REQUIRED:
TOTAL PRACTICUM/FIELD EXPERIENCE HOURS COMPLETED:
Margaret Vicenti
20581683
Bachelor of Science in Elementary Education and Special Education
ELM-351
11/13/2022
Bluffview
Johnnie Schrock
9/19/2022
15.00
22
NM

Clinical Field Experience Verification Form
Placement Course Title
CANDIDATE INFORMATION
Last Name
First Name
Student Number
Candidate Program of Study
COURSE INFORMATION
FACILITY INFORMATION
Facility Name
Type of Facility Facility Setting
Other Facility
Address
City State Zip Code
Country
SCHOOL INFORMATION
School Classification Title One (I)
School District
Principal/Administrator Name
Principal/Administrator Phone
Principal/Administrator Email
20581683
Elementary School
Rural
87401
1204 Camina Real
Public
Farmington
Yes
United States
Farmington Municipal Schools
505 599 8602
[email protected]
Ms. Luann Davis
Bachelor of Science in Elementary Education and Special Education
ELM-351
Bluffview
Vicenti
Margaret
NM

Clinical Field Experience Verification Form
MENTOR INFORMATION
This is the person directly supervising the practicum/field experience activities. Note: This is NOT the GCU
course instructor. Example: Teacher, Administrator, Director, etc.
Mentor Name
Mentor
Email
Address
*
MentorPhone
Number
Mentor Grade
Level
*School/Work Email address required
PRACTICUM INFORMATION
Activities
Please describe the activities completed (Independent Whole Group Instruction, Interview, Administrative Duties) e.g. Observation, Partner Teaching,
Grading, Independent Small Group Instruction,
Date Practicum Activities Started Date Practicum Activities Ended
Total Practicum Hours Completed By Candidate
Additional Information As Applicable
Did your experience include students in any of the following categories? Check all that apply: