University of Dayton 2019
Application for Clinical Experience Date Submitted______________________
Directions: Please complete all pages of the application. All must be on time, complete & error free or will be assessed a late fee of $50.00.
Undergraduate: ___ Spring Semester ___ Fall Semester Graduate: ___ Spring Semester ___ Fall Semester
Due 1
st
Wednesday in February Due 1
st
Wednesday in February
Name: __________________________________ ________________________________ _____________________________
Last First Middle
Permanent Address:________________________________________City:___________________________ST:______Zip:_______
UD Student Identification #: ________________________ Cell #:______________________________________________________
Email:___________________________________________ Date of last FBI/BCI check:____________________________________
If you attended high school in the Miami Valley, list where: __________________________________ Year graduated: ________
Licensure Area:
___ Early Childhood: Kindergarten/Primary (ECE) Field Experiences: List where you were placed for all field
___ 4/5
th
Grade Endorsement experience placements:
___ Early Childhood Intervention Specialist ___________________ __________ _______________
___ Preschool Special Needs District/School Grade Level Subject
___________________ __________ _______________
___ Intervention Specialist (EIS) District/School Grade Level Subject
___________________ __________ _______________
___ Middle Childhood/Intervention Specialist (EIM) District/School Grade Level Subject
EIM Concentrations – Check Two:
___ Math ___ Social Studies Car Available: YES NO
___ Science ___ Reading / Language Arts
___ Generalist Endorsement: RLA MTH SCI SS Extracurricular activities (sports) you have scheduled during
your Clinical Experience year?_________________________
___ Middle Childhood (EMS) By Approval Only
EMS Concentrations – Check Two: Placement Preferences:
___ Math ___ Social Studies Grade level 1
st
Choice____ 2
nd
Choice____
___ Science ___ Reading / Language Arts Subject Area________________________________________
___ Generalist Endorsement: RLA MTH SCI SS Urban______________________ Catholic_______________
___ Adolescence to Young Adult (EYA) Do NOT Place me at_________________________________
EYA Concentration – Check One: NOTE: Candidates will not be placed in a school district
___ Math ___ Social Studies where family members attend or are employed.
___ Science ___ English Language Arts
BA/BS + Licensure Concentration:________________ Are you a full-time, contracted teacher in your own classroom?
____ YES ___ NO
___ Multi-Age (EAG)
___ Art ___ Music
___ Foreign Language: __________________________
Other Special Circumstances:
__________________________________________________
___ Religious Education (ERL)
___ Dyslexia ____ TESOL ___UTA
OFFICE USE ONLY Notes & Remarks
University Teacher Education
Credit Hours______ GPA______ Credit Hours______ GPA______
Concentration_________________ Concentration_________________
Credit Hours______ GPA______ Credit Hours______ GPA______
____ Good Moral Character Form DAP Scores
____ Professional Statement CT OC HI LE Overall
____ ____ ____ ____ ________
____ ____ ____ ____ ________
_______________________________________ _________________ _____________________________ __________
Coordinator Signature/Approved Date Office Signature/Approved Date