MICHIGAN STATE UNIVERSITY

SPECIAL EDUCATION- INTERNSHIP PLACEMENT PLAN

Pre-Internship Meeting, October 8, 2015

*Return completed printed form to Lisa Plascencia in room 337 Erickson Hall, by Friday, Nov. 20, 2015

*Online Internship Placement Plan will need to be completed and submitted by Friday, Nov. 20, 2015

CONTACT INFORMATION

Name______Certification area: ____ LD_____

PID#______MSU Email______

Phone: Local______Cell______Permanent______

Current Address:______

Internship Year Address:______

Summer Address: ______

B. PLACEMENT PREFERENCES FOR 2016-2017 INTERNSHIPS

Please mark appropriate preference with 1 for first priority, 2 for second priority, etc.

Special Education Interns
Endorsement Area Grades Preferred (But not Guaranteed)
General Ed Grade Placement Special Ed Placement
___LD______Lower Elem. K-3rd ______Elementary School
______Upper Elem. 4th-6th ______Middle School
______High School

Major(s):_Special Ed. LD __/Other Major Area:______

and/or Minor(s):______/______

Are you an Urban Educators Cohort Program (UECP or GECP) member? Yes ______No-Cohort______

Geographic Reference: Please indicate the geographic area where you paln to LIVE during the internship. Please indicate any special circumstances that need to be considered regarding your internship placement:

If you have been employed, or you have relatives/significant others* who are employed in schools in the areas you indicated above, please explain your relationships to the person, the position held, the school and the district:

______

What K-12 schools, if any, did you attend in your preference area?______

Do you have children enrolled in schools in the area you requested? If so, what school(s)?______

OTHER? Please write any other important consideration in making your placement on a separate attachment.

C. SIGNATURE

I acknowledge that I have received and read a copy of the Intern Placement Policies. I acknowledge that MSU will attempt to honor my preferences but CANNOT GUARANTEE a placement that closely matches those preferences. I understand that MSU does not permit teacher candidates to make their own placements. I understand that it is my responsibility to meet all the eligibility requirements prior to the internship.

SIGN AND RETURN THIS FORM TO Lisa Plascencia, 337 Erickson Hall- DUE BY NOV. 20, 2015.

______

(Signature)(Date)

D. DELAYING YOUR INTERNSHIP YEAR OR DROPPING THE PROGRAM

My declared internship year is______.

______I will not be interning in the year I originally declared. I am delaying my internship until ______, because (check one reason listed)

_____ Personal reasons (e.g. financial needs, medical needs, travel, exploring other options, personal preference, etc.) Please explain:

_____ Academic extension (e.g. need to finish teacher education coursework, major/minor courses, or degree requirements)

If you have not already done so, please meet with an academic advisor about your extension.

I understand that if I am requesting another internship year other than the one I declared, I will be required to fill out a REQUEST TO CHANGE INTERNSHIP YEAR form. This request form is on the College of Education website at

Please complete the form and return it to the Student Affairs Office, 134 Erickson Hall as soon as possible.

I understand that the Department of Teacher Education will review this request to change my internship year and that the Teacher Education Department cannot guarantee that my request will be approved. I understand that if my request is rejected, I can file an appeal.

I understand that if I delay my internship due to reasons other than academic extension, I may be required to submit a REQUEST FOR REINSTATEMENT TO THE TEACHER PREPARATION PROGRAM when I am ready to return for the internship year. This form can also be found at the above website.

______I am dropping the Teacher Preparation Program. I understand that I must write a letter to the pre-internship coordinator, Andrea Kelly, with a copy sent to the College of Education Student Affairs Office stating that I am dropping the Program or I will complete a withdrawal form in the Student Affairs Office, 134 Erickson Hall.

(Signature) (Date)

*Relatives/significant others means a connection between persons by blood, marriage, adoption, domestic partnership, or other personal relationship in which objectivity might be impaired.