Instructions Request the following:

Instructions
1. Please read this application in its entirety prior to completing.
Request the following:
2. A placement in a school division where you are not employed.
3. A placement in a school division where a family member is not
employed or where a child is not enrolled as a student.
4. No more than one (1) experience per school and per district
5. Submit your typed application to the Center for Professional
Development.
3
Once your observation placement is confirmed, you will have days
to contact your mentor teacher to arrange your observation schedule.
If you do not make this initial contact, your placement is subject to
immediate cancellation.
“Preparing Competent, Compassionate, Collaborative, and Committed Leaders.”
NSU/CPD
Level I Observation (10 Hours)/Level II Observation/Participation (20 Hours)
Field Experience Request Form
Section A: Student Information
Check one: Level I (10 Hours) _______
Last Name:
First Name:
Student ID #:
Phone #: (
Level II (20 Hours) _______
MI:
Major:
)
NSU e-mail address:
@spartans.nsu.edu
Local Address:
(Street)
(City)
Course Abbreviation & Number (EX. EDU 201):
(State)
(Zip Code)
Instructor:
.
Section B: Removing an “I”(If not, go to section C)
Are you removing an “I” from a course? (Check One)
If yes, please list the semester/year:
Yes
No
Course Abbreviation & Number:
Instructor’s Signature is required if completing a course where an “I” was received
Instructor’s Signature:
Date:
Section C: Employment
1. Are you currently employed with a school division? Yes
If yes, please list the district(s):
No
2. Are you currently employed with a daycare center? Yes
If yes, please list the daycare center’s name:
Center location (city):
No
REV 05/2013
Phone #: (
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)
“Preparing Competent, Compassionate, Collaborative, and Committed Leaders.”
NSU/CPD
Section D: Placement Information
Observation Dates: 9/15/14
11/14/14
(Beginning)
This Placement Request is for a
(Ending)
(Check Only One and Complete):
1. Public School Request (No NCOP Students) Local only
School Preference (check one):
Elementary School
Middle School
School Preference:
High School
School District:
Specific Grade Preferred:
Subject Requested:
2. Daycare Center (NCOP Request) Locally or outside of Hampton Roads
Center’s Name:
Center’s Director:
(Last Name)
Director’s Phone #: (
(First Name)
)
Center’s Address:
(Street)
(City)
(State)
(Zip Code)
3. Public School Request (No NCOP Students) Outside of Hampton Roads
School’s Name:
School District:
Specific Grade Preferred:
School’s Phone #: (
Subject Requested:
)
School’s Address:
(Street)
(City)
(State)
(Zip Code)
Human Resources Contact Name:
(Last Name)
Human Resources Phone #: (
(First Name)
)
Initial next to each statement after reading: (INITIALS & SIGNATURES MUST BE HANDWRITTEN)
______ I have read both the CPD Reminders and Guidelines for a field experience. I understand that I am responsible for
abiding by these guidelines throughout my entire experience.
______ I have attached the corresponding city form (applicable only for Virginia Beach, Norfolk, Suffolk, or Chesapeake
school division requests)
______ I have either attached a current, negative TB test and/or a current, negative TB test is already on file with the
CPD.
Applicant’s Signature:
REV 05/2013
Date:
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“Preparing Competent, Compassionate, Collaborative, and Committed Leaders.”
NSU/CPD
Background Verification Form
Addendum to Field Experience and Clinical Practice Applications
All applicants are required to read and verify the following statements when submitting requests
for field placements:
Please sign below to verify the following items:



I have not been convicted of a violation of law other than a minor traffic violation.
I do not have any criminal charges or proceedings pending against me.
I do not have a felony, misdemeanor, or other offense for drugs, sexual abuse, or
assault.
 I understand that if the above mentioned conditions are violated, it can result in
cancellation of the field experience.
If you are unable to verify any of the above items, please give a brief explanation
below and speak with the Director, CPD.
Applicant print name
Signature
Date
Student Comments:
**Do not write below this line--For Office Use Only**
A conference was held with the Director of the CPD on _______________________.
REV 05/2013
Applicant print name
Applicant’s Signature
Director print name
Director’s Signature
Page 4 of 4
Date
Date