SLT Advanced Program Survey
Please provide information about the Practicum Placement you hope to participate in.  My goal is to work with you so that your are successful in completing your endorsement.  

IMPORTANT:
1) If you have not completed the Consent for Sharing Form please do this now.  
2) When you register for the practicum course, please enter LISA FRAGALA as the faculty for course consent.
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Email *
Your legal name: *
Preferred name *
Preferred Pronouns *
What is your teaching situation? *
Where and what are you teaching?  Please describe the grade level, subject area, name of school and school district. *
What endorsement are you currently pursuing? *
When do you expect to do your 90-hr practicum?  You can find this information on your planned program.  *
1) Is there a mentor teacher with whom you are interested in working with in your building or district for your AP placement? (Please remember the mentor teacher must have at least 3 years of teaching experience and an endorsement in the area you are seeking.) *
2) If YES to question 1, what is the mentor teacher's name?
3) If YES to question 1, what does the mentor educator teach?
5) If YES to question 1, what is the mentor teacher's district email address
4) If YES to question 1, how long has the mentor teacher taught? (Remember they must have taught a minimum of 3 years.)
5) If you are currently working in a building have you discussed this with your building principal? *
Please provide your building principals name and email address. *
Have you thought about how your placement will work for you to accrue the 90 hours of practicum experience needed for the endorsement?  (For example: working 1 day per week with the mentor teacher). *
Have you completed the Consent for Sharing Form provided to you in the Welcome Letter from Student Services.  This is a critical step in the process to begin the placement process. *
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