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Clinical Field Experience Verification Form - Johnson 4.1.19.pdf

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CLINICAL FIELD EXPERIENCE VERIFICATION FORMCANDIDATE NAME_________________________ STUDENT NUMBER_____________PROGRAM: ____________________________________________________________________________________COURSE: _____________________________________________________START DATE: ____________________________ END DATE: _____________________PRACTICUM/FIELD EXPERIENCE FACILITY NAME: __________________________________________________________SCHOOL STATE: ___________________________________MENTOR NAME: ___________________________________________________________TOTAL PRACTICUM/FIELD EXPERIENCE HOURS REQUIRED: ______________TOTAL PRACTICUM/FIELD EXPERIENCE HOURS COMPLETED: _____________Georgia MccoyMaster of Education in Special EducationNCKym JohnsonESL-523: English Language Teaching Foundations & Methods10.003/7/20194/17/2019McKee Road Elementary205370321
Clinical Field Experience Verification FormCANDIDATE INFORMATIONLast NameFirst NameStudent NumberCandidate Program of StudyCOURSE INFORMATIONFACULTY INFORMATIONFacility NameType of FacilityFacility SettingOther FacilityAddressCityStateZip CodeCountrySCHOOL INFORMATIONSchool ClassificationTitle One (I)School DistrictPrincipal/Administrator NamePrincipal/Administrator PhonePrincipal/Administrator EmailPlacement Course TitleMaster of Education in Special EducationNCESL-523: English Language Teaching Foundations & MethodsMcKee Road Elementary20537032YesPublicLane PriceCharlotte Mecklenburg Schools980-343-3970MccoySuburban4101 McKee RoadCharlotteUnited States[email protected]Georgia28270Elementary School
Clinical Field Experience Verification FormMENTOR INFORMATIONThis is the person directly supervising the practicum/field experience activities. Note: This is NOT the GCUcourse instructor. Example: Teacher, Administrator, Director, etc.Mentor NameMentor EmailAddress*Mentor PhoneNumberMentor GradeLevel*School/Work Email address requiredPRACTICUM INFORMATIONActivitiesPlease describe the activities completed (Independent Whole Group Instruction, Interview, Administrative Duties)

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Term
Summer
Professor
VIERLING
Tags
Individualized Education Program, Adaptive expertise, Kymberlee Johnson, Candidate Program

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