Course Application for Practice-Based Experience
Note: TWU Professor must complete Sections I-V.
Incomplete applications cannot be processed.
Semester________________________
I. PROFESSOR
Name: Email:
Dept: Cell Phone: (_____________________Work Phone: (______) ______)
Course Number & Section: ______________________________ Number of students to be on-site:
Professor is required to complete the following steps:
Meets with principal of campus (obtains signed DISD Campus Approval Form if requesting Denton)
Announces to class TB Clearances are required by Denton ISD if not born in the US and by Carrollton-FB
Provides List of Student Names and Emails (list will accompany application to school district)
Collects students Criminal Background Requirements (include copy of TB clearance if required)
Includes his/her Criminal Background Requirements (any professor, GA or interpreter that will be on-site)
Acknowledges that he/she has verified the completion of requirements to the best of his/her ability
Submits complete packet to Sharon Masten, SH 202C (allow 3-4 weeks from completed paperwork to start date)
II. LOCATION DESIRED
District: School:
School District Contact (details discussed with): Date:
(Principal, Assistant Principal or Director)
III. PLACEMENT REQUEST
Grade Choice(s): Pre-K K 1 2 3 4 5 6 MS (6-8) HS (9-12)
Type of placement or subject
(Reading, Adapted PE, Dance, etc.):
Day(s) TWU class will be on-site: M T W TH F Time class will be on-site: __________ to
Date scheduled to start experience: __________________________ Total # hours on-site for semester:
(Total Hours)
IV. TWU AUTHORIZATION/APPROVAL SIGNATURE
Professor: Date:
V. PROCESS: Course Application, original Criminal Background Forms, List of Students and any other required documentation must be submitted together to
Sharon Masten, College of Professional Education, located in Stoddard Hall Room 202C. Placements will be recorded and approval emailed by this office to the professor
(allow 3-4 weeks from receipt of completed paperwork to start date). Email questions to
smasten@twu.edu.
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VI. SCHOOL DISTRICT (To be completed by DISTRICT): Once TWU receives the placement approval from the district it is recorded
into our database and the professor is notified.
School Name: Website:
Address: City:
Placement /Teacher’s Name:
Placement’s Grade, Subject or Title:
Placement’s Phone: (_____)_________________________ Placement’s Email:
Is this a Title 1 school? Yes No Accountability: Met Standards Met Alternative Improvement Required Not Rated
Criminal Background Check Approved: Yes No
District Representative (Signature): Date:
Office Use Only
Rec:________ I/C
Letter:_________
Data:___
Conf:___
Email:___________
Please print. Use black ink. Do not staple.
Disclosure of your social security number may be required in order to participate in practice-based experiences at Texas Woman's University. Your social security number will be used for the sole purpose of
processing your criminal history. Any further disclosure of your social security number will be governed by the Public Information Act (Chapter 552 of the Texas Government Code).
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signature
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