Student Request for Field Placement : Keystone College

(*) denotes required information.

* First Name:

* Last Name:

* Email:

* Date of Application

ex. xx/xx/xxxx

* Phone:

* Student ID#

Semester

* Please make a selection:

Fall Traditional Spring Traditional Weekender Fall Weekender Spring Weekender Summer

Degree

* Degree toward which you are working: (choose one)

Early Childhood Education
Early Childhood Education (Pre K-4)
Early Childhood Education (Pre K-4) Special Education (Pre K-8)
Middle Level Language Arts Education (Grades 4-8)
Middle Level Social Studies Education (Grades 4-8)
Teaching: Art Education (Grades K-12)
Teaching: Child and Society
Teaching: Mathematics (Grades 7-12)
Teaching: Social Studies (Grades 7-12)
Early Childhood Education
Elementary Education
Art Education
Math Education

Courses

* Check appropriate course(s) for which you are seeking field experiences:

ECE 101 ECE 201 ECE 202 ECE 303 ECE 304 ECE 305 ECE 315 ECE 325
EDUC 101 EDUC 215 EDUC 306 EDUC 317 EDUC 327 EDUC 332 EDUC 335 EDUC 337
EDUC 340 EDUC 345 EDUC 355 EDUC 405 SPED 225 SPED 230 SPED 235
SPED 310 SPED 320 SPED 325 SPED 330 SPED 340 SPED 350 SPED 360
SPED 410 PSYC 222 PSYC 224 PSYC 230 PSYC 355 EDUC 201 EDUC 302
EDUC 310 EDUC 315 EDUC 330 EDUC 331 EDUC 216

Clearances

Please indicate when you received your clearances. They must be current for the designated school year.

* Date Criminal History Clearance was received:

ex. xx/xx/xxxx

* Date Child Abuse Clearance was received:

ex. xx/xx/xxxx

* Date Health Appraisal/TB Test was received:

ex. xx/xx/xxxx

* Date FBI clearance was received:

ex. xx/xx/xxxx

Field Experience

* PDE Stages of Field Work

Field Experience I - Observation
Field Experience II - Initial Experience
Field Experience III - Pre-Student Teaching
Field Experience IV - Student Teaching

Times Available

Indicate the times you are available for observation/participation.

Example: 8am-3pm. Put N/A if not available at all during that day.)

* Monday

* Tuesday

* Wednesday

* Thursday

* Friday

School Information

If appropriate we will honor this request. Please indicate a school building and the district(s) with which you are familiar that might fulfill this requirement. Provide the name of a teacher who may be willing to accept a placement. However, to ensure that students experience a wide range of observation assignments, placement in a variety of school settings is suggested and will be arranged.

Name of Teacher:

Keystone College reserves the right to place students in a setting best suited for observation experiences that are developmental in nature. If at all possible, placement in a school district closest to home or employment will be made.

Students are responsible for their own transportation.