F72F382F-C8FF-4618-96F3-35D4BFF89A51_637461510653687803.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: Nitzandra Rivera MedinaMaster of Education in Special EducationILMary BlakeSPD-521: Collaborations and Communications in Special Educ6.0011/19/20201/13/2021Oakdale Elementary School206514856.00
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 Special EducationILSPD-521: Collaborations and Communications in Special EducationOakdale Elementary School20651485YesPublicCatalina QuinonesWaukegan Public School2243031860Rivera MedinaSuburban2330 Mc Aree RdWaukeganUnited States[email protected]Nitzandra600876Elementary School
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

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Term
Spring
Professor
N/A
Tags
Individualized Education Program, Candidate Program, Mary Blake, Nitzandra Rivera Medina

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