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Clinical Field Experience Verification Form - FPC - signed.pdf

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CLINICAL FIELD EXPERIENCE VERIFICATION FORM CANDIDATE 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: _____________ Ra'monika CarterMaster of Education in Early Childhood EducationLAAaliyah TaylorECE-530: Health, Safety, and Nutrition in Growth and Developm10.001/23/20203/4/2020St. Paul the Apostle Head Start2020783210.00
Clinical Field Experience Verification FormCANDIDATE INFORMATIONLast NameFirst NameStudent NumberCandidate Program of Study COURSE INFORMATIONFACULTY INFORMATIONFacility NameType of FacilityFacility SettingOther FacilityAddressCityStateZip CodeCountrySCHOOL INFORMATIONSchool ClassificationTitle One (I)School DistrictPrincipal/Administrator Name Principal/Administrator Phone Principal/Administrator Email Placement Course TitleMaster of Education in Early Childhood EducationLAECE-530: Health, Safety, and Nutrition in Growth and Development of Early LearnersSt. Paul the Apostle Head Start20207832YesPublicPamela RandallOrleans Parish5045031234CarterSuburban6828 Chef Menteur HighwayNew Orleans[email protected]Ra'monika70126Early Childhood Learning C
Clinical Field Experience Verification FormMENTOR 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 NameMentor Email Address *Mentor Phone NumberMentor Grade Level*School/Work Email address requiredPRACTICUM INFORMATIONActivities

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Term
Summer
Professor
Jodi Palmer
Tags
Candidate Program, Ra monika Carter

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