Form: Clinical Experience Application for Practicum Courses

Owner: JSU Administration <jsuadmin>
Owner's Email: dherring@jsu.edu
Dataset: Clinical Experience Application for Practicume Courses
EDIT: Y, VIEW: N, REQR: Y
1
Date: *
 (MM/DD/YYYY)
EDIT: Y, VIEW: N, REQR: Y
2
First Name: *
EDIT: Y, VIEW: N, REQR: Y
3
Last Name: *
If information changes after you fill out this application, please notify rray@jsu.edu.
EDIT: Y, VIEW: N, REQR: Y
4
Major: *
EDIT: Y, VIEW: N, REQR: Y
5
JSU ID# *
Format (000000000) NO dashes
Include ALL 9 digits
EDIT: Y, VIEW: N, REQR: Y
6
School Year Residence Address: *
This is where you will live during your practicum.
All placements will be made based on this information. If information changes after you fill out this application, please notify rray@jsu.edu.
EDIT: Y, VIEW: N, REQR: Y
7
City: *
EDIT: Y, VIEW: N, REQR: Y
8
State: *
EDIT: Y, VIEW: N, REQR: Y
9
Zip: *
EDIT: Y, VIEW: N, REQR: Y
10
Residence Phone Number: *
If information changes after you fill out this application, please notify rray@jsu.edu.
EDIT: Y, VIEW: N, REQR: Y
11
Cell Phone Number: *
If information changes after you fill out this application, please notify rray@jsu.edu.
EDIT: Y, VIEW: N, REQR: Y
12
JSU email: *
This will be used to communicate with you before and during Practicum.
EDIT: Y, VIEW: N, REQR: Y
13
Name all schools in which you have children and/or relatives currently attending/employed: *
Please document the specific school name, not just the city or district.
EDIT: Y, VIEW: N, REQR: Y
14
Education History: Please list the system/school name and actual years attended below. *
system name, school name, and range of years attended for K-12
EDIT: Y, VIEW: N, REQR: Y
15
Term Requesting Practicum Placement *
EDIT: Y, VIEW: N, REQR: Y
16
Practicum For Which You Are Currently Registering *
EDIT: Y, VIEW: N, REQR: Y
17
Previous Clinical Experience: List the name of all schools (with grade levels) where you have completed practicum hours. *
Placement will be delayed without complete information.
EDIT: Y, VIEW: N, REQR: N
18
For Employed Graduate Students - Employment Verification
In order for you to meet requirements for your clinical experience while you are employed, you must be employed in the area/field you are seeking your masters in and within the certification range (grade levels) that accompanies that certification. List the position in which you were hired (include subject area and grade level(s):
EDIT: Y, VIEW: N, REQR: N
19
Are you employed in the exact area and grade level(s) in which you are seeking certification?
Yes
No
EDIT: Y, VIEW: N, REQR: N
20
List the school system where employed:
EDIT: Y, VIEW: N, REQR: Y
21
I understand that it is my responsibility to provide proof of professional liability insurance to my practicum instructor. I also understand that I may not begin any clinical experience until I receive placement information from a JSU official. *
Yes
No