Directions for Completing the Application Form for Clinical Placements

Directions for Completing the Application Form for Clinical Placements

Directions for completing the application form for clinical placements

  1. Highlight the form and copy/save to your computer.
  2. Review the application information.
  3. Confirm that you have met the placement requirements (GPA, admission to the department, methods course requirements, major department approval, passage of the Praxis exam – student teaching) before filling out the application. No application will be fully processed without meeting the appropriate placement requirements.
  4. Complete the application form. Note:
  5. Conflicts of interest include relatives (parents, grandparents, children, brothers or sisters in the school), or past employment or experience in the school.
  6. Review the application form for spelling or grammatical errors.
  7. Delete any red type.
  8. Print a copy of your current transcript from the Western administration system. Attach that copy to your application.
  9. Print off two copies of your application form, keeping one for your records and giving one to Ms. Tina Dye(with your attached transcript) by the date due.

10. As you determine your semester schedule, please remember to allow for sufficient time to complete your placement experience and to accommodate travel time. At a minimum this should be two hours for junior experience. For practicum placements, your time commitment will be much greater.

Date: ______

Please identify the semester/year for your clinical experience______

Name:______Semester/year ______

Date of Birth: ______SSN# & G-Code______

Gender:______Cell Phone Number:______

Phone Number:______Advisor:______

Email:______

Ethnic Origin:______

Local Address:______

______

Permanent Address:______

In keeping with the requirements of Title IX of the education Amendments of 1972 in regard to sex discrimination and Section 504 of the Rehabilitation Act of 1973 in regard to handicap discrimination as well as other applicable federal and state laws, Missouri Western State College follows a policy of nondiscrimination and equal opportunity in regard to all employment practices and to all educational programs and activities including student financial aid, recruitment, admission, housing, and placement. Inquiries regarding the application of these laws may be submitted to Michael Ritter, the Title IX, 504/ADA Coordinator, Eder Hall, Room 202B.

Major:

Concentration Area or Minor:

Assignment Scheduling: . Students in 303 are in the schools one hour a day, five days a week. A two hour time block is required to be set aside for this experience. The time block must me the same time everyday. No exceptions to scheduling time requirements.

Requested times(two hour block required):______

I am applying for a placement in:(Course designation and number)______

High School Attended:______

(Name, City, State)

Other schools attended or in which you may have a conflict of interest: (List each school, city, state)

Education coursework: Please list the education coursework by course name and number and the grade received for all education coursework taken to date. Secondary students: this includes all your methods courses for your major.

Please list any past teaching or leadership experiences:

.

You must meet the following criteria to participate in Teaching II: 2.5 GPA, admission to the Education Department, completion of required methods’ courses (elementary majors – EDU 310, 320, 330, 340, 360 and MAT 351-352. Secondary students must meet major department requirements.

Students seeking 303 placement should identify the level of experience preferred. For example elementary teachers can request grades 1, 2 or 3 for Experience in Teaching II and would then be placed in grades 4, 5 or 6 for Experience in Teaching III.

K-12 certifications (art, foreign language, physical education, music, speech/theater) should indication a request for placement based on the interest in student teaching. If you want to student teach at the high school level then choose elementary or middle school for teaching II experience. Choose wisely and know the district that you are requesting.

Placement level requested for Experience in Teaching II (grade level):______

Please provide a brief personal statement (100-200 words) sharing your personal goals statement related to a teaching profession.

Signature:______

Date:______

By submitting this application you are affirming that all information is accurate and complete. Failure to disclose or provide accurate information may result in your removal from the placement application process.

Attach a copy of your current transcript to this application.

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