Graduate School of Education

Early Intervention/Early Childhood SPED Placement Application

Name
Program

Field Placement Application

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

Information provided will be shared with district/agency personnel.

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

I am currently employed: No Yes If yes, please indicate district/school/agency:

Please list any additional information that would be helpful in securing a placement for you (field will expand as you type):

Complete the form, save it as a Word document by naming it “Last Name, First Name,” and send as an attachment to Field Placement Coordinator, at .

Preferred placement schedule (for practicum/part-time):

Days of the week: / Time of day:
Mon
Tues
Wed
Thurs
Fri / Morning
Afternoon
No preference
Desired Geographic Area
The Field Placement Office collaborates with faculty and district or agency personnel to secure quality field experiences for you. You are NOT guaranteed an experience in a specific district or geographic area. You will be responsible for securing transportation to and from your assigned site. Please initial that you have read and understand this information.
North/Northwest Portland Metro Area / South/Southwest Portland Metro Area
Northeast Portland Metro / Southeast Portland Metro
Other:

Name: PSU ID: Term/Year Admitted:

(Last)(First) (MI)

Address:

(Street)(City)(State) (Zip)

Email:Preferred Phone: () Cell Home

Once your PSU email address has been assigned, you are responsible for checking it regularly.

If any of your contact information above (including name) changes, notify the Field Placement Office immediately.

Educational Background:
High School/College Attended / City/State / Major / Degree Earned / Dates
Experience working with children and families(list most recent first):
District/School or Agency / Dates / Length of Experience
(hours, days, months) / Responsibilities (Be specific)
Other Work or Military Experience:
Position Held / Type of work / Company or Organization / Location / Dates
Activity/Sport: / List: Organization (if applicable):
Other Languages: / List: Proficiency (check all that apply): Read Write Fluent
Experience with ELLs: / 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:

Submit a fingerprint packet to TSPC.

Submit this form to the Field Placement Office.

I understand that before I can begin my placement, I must:

Pass all required tests (Civil Rights Exam)

Complete all program prerequisites

Submit proof of fingerprint clearance toSPED Admissions (Kris Smith - )

Submit proof of First Aid and CPR training to SPED Admissions

I understand that I will not be placed in a school district or agency in which a family member works or attends.

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

I understand that I must conduct myself in accordance with all policies of the district, agency, school and/or program in which I am placed for my student teaching 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 agencies to assist in the placement process.

Signature: Date:

SUBMIT COMPLETED FORM TO:

Andi Pearson, Field Placement Coordinator,

Graduate School of Education FAB 210-16, PO Box 751, Portland, OR 97207

7/22/2014 1