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24-Student Teacher Placement Form
(observation/practicum/student teaching/internship/clinical experience)
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WELCOME TO THE BERKELEY TOWNSHIP SCHOOL DISTRICT!
Date of placement request
*
MM
/
DD
/
YYYY
University Information
University
*
Your answer
Placement Coordinator
*
Your answer
Placement Coordinator email address
*
Your answer
Placement Coordinator phone number
*
Your answer
Student Information
Student Name
*
Your answer
Mailing Address
*
Your answer
Phone Number
*
Your answer
Alternate Phone Number
Your answer
Email Address
*
Your answer
Anticipated Date of Graduation
*
Your answer
Date of Background Check (Fingerprinting)
*
MM
/
DD
/
YYYY
Application for:
*
Choose
Practicum
Student Teaching
Clinical Experience
Internship
Please fill out below only if this is an internship.
*
Choose
Administration
Counseling
Student Services (Physical Therapy, School Psychologist, School Social Worker, etc.)
Other
Placement Type
*
Choose
Observation Only
Observation with Teaching
Placement for
*
Fall Semester
Spring Semester
Do you need multiple placement settings?
*
Yes
No
Number of hours requested
*
Your answer
Number of hours per teacher/experience
*
Your answer
Preferred Grades
*
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Special Education
Other:
Required
Schools of Interest
*
Bayville School (Pre-K through 4th)
Clara B. Worth School (Pre-K through 4th)
H & M Potter School (Pre-K through 4th)
Berkeley Township Elementary School (5th and 6th Grade)
Required
I verify the accuracy and completeness of the information submitted.
(By typing your name below this form has the same legal force and effect as my handwritten signature)
Preparer's Name
*
Your answer
Preparer's Email
*
Your answer
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