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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: Alexandria RogersMaster of Education in Secondary EducationCAKiana FrazierSEC-540: Adolescent Literacy15.005/6/20216/16/2021Bright Futures Academy2076170410
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 Master of Education in Secondary EducationCASEC-540: Adolescent LiteracyBright Futures Academy20761704YesPrivateLisa NoeRiverside Unified School District9513733793RogersSuburban9994 Country Farm RdRiversideUnited States[email protected]Alexandria92504Other
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 * Mentor Phone 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,

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Term
Fall
Professor
Sandra Jones
Tags
Disposition, Adaptive expertise, Alexandria Rogers, Kiana Frazier

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