COLLEGE OF ARTS & SCIENCES,
AND
EDUCATION
Office of Field Services and Professional Development Schools
2500 West North Avenue, Baltimore, Maryland 21216
Grace Hill Jacobs Room 709; (410) 951 – 3081
“Educator as Reflective Facilitator of Learning
Revised Fall 2015
Application for Field Experience Placement
Part I: Completed by Applicant
_________________________________
Date of Application
Name: __________________________________________ Student ID: ________________________________
Email Address: _____________________________________________ GPA: __________________________
Advisor: _________________________________________ Major: _______________________________________
Semester Requested Fall Spring Year _____________________
Course Affiliated with Field Experience Request: __________________________ Hours Required: _________________
Course Instructor: ________________________________________ Expected Date of Graduation: ______________
Type of Experience Requested: (Check response) Observation (Early) Participation (Methods)
Are you currently enrolled in other courses that require field experience? Yes No
CSU has partnerships with six schools. Rank your preference for field experience placement below. NOTE: Methods
courses are taught on site at Rosemont Elementary/Middle with field experience completed at that site.
_____ Rosemont Elementary/Middle _____ Gwynns Falls Elementary _____ Coppin Academy High
_____ John Eager Howard Elementary _____ Robert Coleman Elementary _____ Pitts-Ashburton Middle
Indicate sites where you have completed field experiences: ______________________________________________
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Signature of Applicant Date
Part II: Completed After Placement Collaboration by Site Liaison & CSU Director of Field Services & PDS
School Assignment: ________________________________ Principal: ____________________________________
Grade/Subject: ______________________________ P-12 Clinical Educator:_________________________________
CSU Course: ______________________ Hours Required: ________ Experience Focus: _____________________
Start Date: ________________ End Date: ___________________
Comments: ________________________________________________________________________________________
LEA Administrator’s Signature: ___________________________________________ Date: _____________________
PDS Director’s Signature: ________________________________________________ Date: _____________________
Upon placement, copy provided to Department Chair and Course Instructor; Original retained in PDS Office.
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