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: ______________________________________________
__________________________________________________________________________________________________
___________________________________ ______________
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.
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
