field-experience-app-ited-2017.doc - Dewar College of...

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Dewar College of Education and Human Services Application for Field Experience Placement Please TYPE IN your responses or PRINT your responses legibly. Internship/Field Experience Course: _________ Section: _____ Instructor: _______________ _ Name: ______________________________________________VSU ID #: 870 -_________ Your VSU e-mail address: ______________________________ ________________________ Your work e-mail address: Address: (Street Address) _________________________________________________ Phone: (____) ___________ (City) (State) (ZIP Code) Have you worked in a school setting? ______ Yes ______ No If yes, please list the school and capacity: Are you currently employed in a school setting? ______ Yes ______ No If yes, please list the school and capacity: Do you have any medical conditions of which the university or the field experience site should be aware? ______ Yes ______ No If yes, please describe: ________________________________________________________ _ ____________________________________________________________________________ Do you have any special needs ** that should be considered in making your field experience placement? ______ Yes ______ No ( ** Special Needs —Health Problems or Personal Issues) If yes, please explain : _________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Revised 02.15.2017 1 | P a g e
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Please consider the following points VERY carefully: Once placements are made, they will not be changed.
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  • Winter '16
  • ProfessorDuncan
  • field experience placement

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