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”
Return the completed form to the Office of Field Services – GJ 709
Revised Fall 2015
Clinical Practice Application
__________________________________
Date of Application
PERSONAL INFORMATION
Name: ______________________ ___ ___________________ ___/___/___ ___________________
First MI Last Date of Birth Student ID #
Local Address: ______________________________________________________________ _________________________ _______ ____________
Street/Apt # City State Zip
Phone #: __________________________________ Email Address: ______________________________________________________
Academic Major: ______________________________________ Minor: ______________________________________
GPA: ________________ Expected date of Graduation: __________________________
ADDITIONAL INFORMATION (Check appropriate answer)
Yes No
□ □ Have you ever been convicted of violation of law other than a minor traffic ticket?
□ □ Do you have criminal changes or procedures pending?
If you answer “yes” to any of the above questions, please explain on a separate page and attach.
Complete your early field experience information below
Course Semester/Year Placement Site Grade Observed P-12 Clinical Educator # of hours completed
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ADDITIONAL INFORMATION (Please indicate the correctness of each statement by initialing on each space provided.)
____________ I have completed all general education requirements
____________ I have completed major and minor course requirements
____________ I have a grade point average of at least 2.5.
____________ I have □taken □passed all Praxis II requirements. (Indicate the correct response by checking the appropriate box.)
____________ I have □taken □passed the interview requirement. (Indicate the correct response by checking the appropriate box.)
____________ I have □taken □passed the essay requirement. (Indicate the correct response by checking the appropriate box.)
____________ I have completed the required physical examination requirement.
