ADMISSION TO SINGLE SEMESTER
CLINICAL EXPERIENCE
Information and Instructions
Kennesaw State University
Education Preparation Provider
Center for Education Placements and Partnerships
FALL SINGLE SEMESTER SPRING SINGLE SEMESTER
CLINICAL EXPERIENCE CLINICAL EXPERIENCE
Apply by previous January 30 Due: September 15, 2016
By end of business By end of business
Application for admission to Clinical Experience is complete when all items below have been submitted in ONE PACKET to the Center for Education Placements and Partnerships (CEPP), Kennesaw Hall, Suite 1002.
1. CLINICAL EXPERIENCE APPLICATION.
Read the Placement Request Instructions on the CEPP website. Fill out the application on line. Print three copies. Keep one copy for your file. Read carefully the last item on the application, “Release of Information,” sign and date two of the printed copies and submit both copies in your application packet. One copy remains in the CEPP file; the other is sent to the school system you requested. If you need to make a change to your application do so online by the above due date.
2. ADVISOR REVIEW.
Make an appointment with your advisor. Take a copy of the “Advisor Review” form to the appointment. Ask your advisor to complete the form and sign it. Make one copy of the completed “Advisor Review” for your file and turn in the original, signed copy in your application packet. The original, signed copy remains in the CEPP files.
3. CRIMINAL HISTORY CONSENT FORM.
Fill out the top part of the form only. Turn in the original, signed form in your application packet along with one (1) copy.
· Criminal History Consent forms with crossed-out information or use of white out (correction tape) will not be accepted by CEPP or the school systems. If an error is made, please print and complete a new form.
· Marietta City School System requires the student teachers assigned to Marietta City Schools attend an orientation before the student teaching experience begins. Marietta City School System will contact the teacher candidate(s) regarding date and time of this orientation.
4. VERIFICATION OF LIABILITY INSURANCE
Please attach a copy of your membership card to the clinical experience application.
5. VERIFICATION OF PRE-SERVICE CERTIFICATION
Please attach a copy of your pre-service certificate issued by the PSC to the clinical experience application. If you do not have a pre-service certificate follow the steps below:
· http://bagwell.kennesaw.edu/centers/ess/educator-certification/pre-service-certification
· For the Pre-Certification application, complete only pages 1 & 3, you can disregard page 2. And note that there is no fee required for this pre-cert application.
· Verification of Lawful Presence (VLP) - Make sure the copy of your driver's license or legal id is clear. This form must be signed in the presence of, and stamped by, a Notary Public. KSU Students can utilize Notaries in Education Student Services (Kennesaw Hall), Registrar or Financial Aid at no cost.
· The above should be turned in to ESS, Kennesaw Hall, Suite 1314.
· Do not process these forms thru the PSC.
· Do not bring these forms to CEPP
CLINICAL EXPERIENCE APPLICATION PACKET must contain:
_____1. Clinical Experience Application. 2 copies
_____2. Advisor Review. Original
_____3. Criminal History Form. Original plus 1 copy
_____4. Verification of Liability Insurance
Attach a copy of your SGAE, SPAGE OR EDUCATOR’S FIRST membership card to the clinical experience application.
_____5. Verification of Pre-Service Certification
(copy of certificate from mypsc account)
______
Print Name Date
Criminal History Consent
Form for Clinical Experience
Kennesaw State University
Center for Education Placements and Partnerships
I authorize any school district in the State of Georgia to receive any criminal and/or driver’s history record information pertaining to me which may be in the files of any state or local criminal justice agency. Further, I give consent to the school systems to perform periodic criminal history background checks for the duration of my student teaching experience without seeking additional consent from me. I further understand that neither the Georgia Crime Information Center (GCIC), its employees, nor any other agency or employees of the State of Georgia shall be responsible for the accuracy of information nor have any liability for defamation, invasion of privacy, negligence or any other claim in connection with any dissemination of information pursuant to this record check, and shall be immune from suit based upon such claims.
PLEASE PRINT
______
Last Name First name Middle Maiden
Street Address City State Zip
Gender Ethnicity DOB Social Security Number
Home Phone Cell Phone Driver’s License # or State ID# State Issued
______
Signature Date
------Do Not Write Below—For School System Use Only------
Signature Title Date
Employment Date Terminal Operator
______ORI# Agency
NOTES:______
August 2007
ADVISOR REVIEW
Of Eligibility for Clinical Experience
Kennesaw State University
Bagwell College of Education
Center for Education Placements and Partnerships
Candidate______
Current GPA______
Courses in which the candidate is currently enrolled:
______
______
Required courses not yet completed and the semester the candidate plans to complete them:
I have examined the transcript (and other records) of the above candidate and I support his/her application for a clinical experience placement for
______Semester, 20______.
Advisor Signature Date
Advisor Comments:
______
Packet Revision January 2016