25800 Carlos Bee Boulevard, AE 235 Hayward, CA 94542
510.885.2272 www.csueastbay.edu/cssc
Please return this form to applicant, for applicant to submit with application documents.
First & Last Name ___________________________________________ Last 4 SSN_________
Multiple Subject Single Subject in: _________________________
Title 5 Regulations fro
m the California State University Chancellor’s Office requires each credential candidate to have
participated in a supervised Early Field Experience in a public school classroom and/or classroom-like setting prior to
application to a credential program. The Early Field Experience is designed to simulate the credential you are seeking so
we may gain a preliminary assessment of your potential as a classroom teacher. You must have participated in an early
field experience with a group(s) of school-aged children appropriate for the age group you are pursuing your teaching
credential within the last 3 years.
This form must be completed and signed by a Supervisor or Teacher.
A. Type of Early Field Experience:
After School Program Aide/Volunteer
Teacher's Aide/Instructional Aide
Substitute Teacher
Teacher's volunteer
Boy Scouts, Girls Scouts, YMCA
Camp Counselor/Volunteer
Other: ___________________________
B. Name of Organization/School: _____________________________________
County________________ City, State_____________________________
C. Approximate age of children: From: years old to years old
D. Number of Children (in group): Approximately ______
E. Dates of Early Field Experience: From
______/____/_____ to ____/____/____
F. Total hours (needs to be filled out): ________________
G. Please briefly explain what type of activities applicant lead/facilitated.
Supervisor/Teacher name (print): _____________________ Position/Title: __________________
Supervisor/Teacher signature: _________________________________ Date: ________________