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: the form is three pages but should be expanded to meet your application needs.
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 Dr. Bogle (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.
11. A final placement cannot be made for practicum and junior experience applications without a copy of your schedule for the semester of the placement. Please be sure you print a copy of that schedule and give to Dr. Bogle by October 11/April 15.
Missouri Western State University
College of Professional Studies
Department of Education
Application for Clinical Placement
Dr. Bogle
Date:______
Experience being applied for (Course #):
Please identify the semester/year for your clinical experience______.
Name:
SSN#/G-Code
Date of Birth:
Gender:
Phone Number:
Cell Phone Number:
Email:
Advisor:
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 the 203 classes are scheduled into a SJSD classroom two times per week for two hours per day. Students in the 303, 389 are in the schools one hour a day, five days a week. Students in 460 must be in schools two hours and fifteen minutes a day, five days a week. 425 and 461 are in classrooms three hours per day, five days per week. Students in the 408/409 classes are scheduled for eight hours per day for the duration of student teaching. Most elementary classes begin around 9 AM and end between 3:00 – 3:30 PM; most secondary classes begin around 7:50 and end around 2:40 PM.
I am applying for a placement in:(Course designation and number/same as above)______
Requested days/times (203s only)______
Requested times (303, 389, 425, 460, 461, only):______
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. EDU 203 applicants are excused from this section. Secondary students: this includes all your methods courses for your major.
Multicultural/diversity interview/paper: (Please attach a graded copy of your multicultural/diversity paper)
What did you learn from this experience?
Juniors and Student Teachers: Documentation of having addressed at least two of the Western Teacher Leadership dispositions
(Please attach a graded copy of your dispositions paper)
Please list any past teaching or leadership experiences:
Student seeking any placement other than 203 must have met the following requirements: 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 - junior experience/practicums), major department requirements, major department approval (student teaching) and passage of the required PRAXIS exam (student teaching).
Students seeking 303 placement should identify the level of the experience for junior/student teaching. For example elementary student teachers can request grades 1, 2 or 3 for junior experience and would then be placed in grades 4, 5 or 6 for student teaching. Middle school students should identify the content area for junior experience. K-12 certifications (art, foreign language, physical education, music, speech/theater) should indication a request for junior 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 junior experience. Choose wisely and know the district that you are requesting.
Placement level requested for junior experience (grade level):______
School assigned and grade level for junior experience (student teachers only)______
Placement level requested for student teaching (grade level):______
School district for student teaching:1)______
2)______
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.