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CLINICAL FIELD EXPERIENCE VERIFICATION FORMCANDIDATE NAMESTUDENT NUMBERPROGRAM: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:Nitzandra Rivera MedinaMaster of Education in Special EducationILBeatrice ReyesSPD-540: Learning Environments for Students with Mild to Mod9.002/25/20214/7/2021Clearview Elementary206514859
Clinical Field Experience Verification FormPlacement Course TitleCANDIDATE INFORMATIONLast NameFirst NameStudent NumberCandidate Program of StudyCOURSE INFORMATIONFACILITY INFORMATIONFacility NameType of FacilityFacility SettingOther FacilityAddressCityStateZip CodeCountrySCHOOL INFORMATIONSchool ClassificationTitle One (I)School DistrictPrincipal/Administrator NamePrincipal/Administrator PhonePrincipal/Administrator EmailMaster of Education in Special EducationILSPD-540: Learning Environments for Students with Mild to Moderate DisabilitiesClearview Elementary20651485YesPublicSandy JohnsonWaukegan public School2243031600Rivera MedinaSuburban1700 Delaware RdWaukeganUnited States[email protected]Nitzandra60087Elementary 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 NameMentorEmailAddress*Mentor PhoneNumberMentor GradeLevel*School/Work Email address requiredPRACTICUM INFORMATIONActivities

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Term
Summer
Professor
NoProfessor
Tags
Individualized Education Program, Adaptive expertise, Candidate Program, Beatrice Reyes

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