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 InternsEndorsement 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.