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tion for Directed Professional Experience Applica (Alternate Program) (York College of Pennsylvania)

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Applica
tion for Directed Professional Experience
(Alternate Program)
The Directed Professional Experience is an alternate program that may be taken in lieu of the
professional semester coursework. Completion of this alternate program will not qualify a student
for teaching certification in any state.
Student Name: ___________________________________ Student ID#: ___________________
Current Address: ________________________________________________________________
(Street and #) (City) (State) (Zip code)
Student Contact Information: ____________________________________ _______________
(Phone number) (Email)
Major: ______________________________________ Advisor: _________________________
Reason for Requesting Directed Professional Experience (check one):
_____ The alternate program in lieu of student teaching
_____ Other: __________________________________________________________________
Coursework (to be completed by the student and advisor):
Anticipated Directed Professional Experience Semester and year: ______________________
Anticipated Directed Professional Experience Credits (choose 1):
2 credits 3 credits 4 credits
Additional coursework for which student will register (if applicable):
Course(s): Credits:
____________________________________________ _______________
____________________________________________ _______________
____________________________________________ _______________
____________________________________________ _______________
ADVISOR SIGNATURE:
__________________________________________________________DATE: _______________
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signature
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Location of Experience (student secures this placement):
Agency Name: _________________________________________________________________
Agency Address: ________________________________________________________________
(Street and #) (City) (State) (Zip code)
Agency Cooperating Mentor Name: _________________________________________________
Agency Cooperating Mentor Contact Information: ____________________ _______________
(Phone number) (Email)
MENTOR SIGNATURE:
_________________________________________________________DATE: _______________
Student Acknowledgements
• I am responsible for securing alternative, off-campus placement(s) and mentors.
• I am responsible for developing a proposed plan and sharing it with all parties involved.
• I have read the Directed Professional Experiences Handbook.
• I understand that, upon successful completion of this Directed Professional Experience in
Education in lieu of Student Teaching, that I will not be eligible for state teaching
certification.
• I am aware that college faculty/administration reserve the right to remove a college student
from any course and I must abide by all professional dispositions of the Department of
Education.
• In order to successfully complete this Directed Professional Experience, all activities
described above must be completed in a satisfactory manner, including required hours.
STUDENT SIGNATURE:
_________________________________________________________DATE: _______________
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Approvals (to be completed by the Department of Education):
Directed Professional Experience Semester and year: ______________________
Directed Professional Experience Credits: ______________________ Course #:__________
DIRECTOR OF FIELD SERVICES SIGNATURE:
_________________________________________________________DATE: _______________
DEPARTMENT OF EDUCATION CHAIRPERSON SIGNATURE:
_________________________________________________________DATE: _______________
College Supervisor Name: _________________________________________________
College Supervisor Email: _________________________________________________
Additional Comments:
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Completed 2 September 2020

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