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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.)
Placement Type
Choose
Observation Only
Observation with Teaching
Placement for
Fall Semester
Spring Semester
Clear selection
Do you need multiple placement settings?
Yes
No
Clear selection
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:
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)
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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