Student Teaching Application

Graduate School of Education GTEP Field Placement Application

OFFICE USE ONLY DATES: PROGRAM: STUDENT TEACHING TERM(S) REQUESTED: COHORT LEADER(S): PRACTICUM HOURS PER WEEK: WORK SAMPLE REQUIRED

Field Placement inquiries are facilitated through the PSU Field Placement Office. You may not seek your own placement or have conversations with districts, administrators or teachers about a placement possibility. Please wait to be contacted by a School District or the Field Placement Office.

Information provided will be shared with school and district personnel.

Name: , PSU ID: Term/Year Admitted: (Last) (First) (Middle) Address: (Street) (City) (State) (Zip)

Email: Preferred Phone: ( ) Cell Home Work

Once your PSU email address has been assigned, you are responsible to check it regularly. If any of your contact information above (including name) changes, notify the Field Placement Office immediately.

Authorization Level: Endorsement Area: Please choose one or two in order of preference For ML/HS only, indicate the subject you would like to teach Early Childhood (K–3) Middle Level (5–10) Elementary (3–8) High School (9–12)

We attempt to make the majority of our field placements in pre-established partner schools. If there is information you would like us to consider related to clinical field placements, describe them here (field will expand as you type):

Educational Background: High School/College Attended City/State Major Degree Earned Dates

Experience working in an educational setting (list most recent first): Length of Experience School or Agency Dates Responsibilities (Be specific) (hours, days, months)

Work or Military Experience: Position Held Type of Work Company or Organization Location Dates

[Type text] Graduate School of Education GTEP Field Placement Application Page 2

Activity/Sport: List: Organization (if applicable): Foreign Languages: List: Proficiency (check all that apply): Read Write Fluent Experience with ELLs: Yes No Where: Experience with SPED: Yes No Where: Other relevant experiences

not listed above: ***Please initial that you have read and understand the following.***

I understand that before I can be considered for placement, I must: Begin the fingerprint clearance process through TSPC. Submit this form to the Field Placement Office.

I understand that before I can begin student teaching, I must: Pass all required tests Complete all program prerequisites. Submit proof of fingerprint clearance to the program. Provide evidence of professional liability insurance.

I understand that I will not be placed in a school which I attended, or in which a family member works or attends. Please indicate here which schools you have children attending or family members working, if any:

I understand that I am not to have contact with a specific cooperating teacher, principal, or district personnel, and shall not make any arrangements with a school district for my student teaching placement. Violation of this protocol could be cause for loss of my teaching placement.

I understand that I am not guaranteed an experience in a specific district or geographic area and that I am responsible for securing transportation to and from my assigned school site.

I understand that I must conduct myself in accordance with all policies of the district, school and/or program in which I am placed for my clinical experience.

Your typed name below signifies agreement to the above statements and authorizes the Graduate School of Education to use its discretion in providing your personal information to districts and/or schools to assist in the placement process.

Signature: Date:

SUBMIT COMPLETED FORM TO: Penny Jasso, Field Placement Coordinator [email protected] GRADUATE SCHOOL OF EDUCATION FAB 210, PO BOX 751, PORTLAND, OR 97207

Edited 6/1/2016