SOPHOMORE FIELD EXPERIENCE PLACEMENT REQUEST CARD

(PLEASE TYPE OR PRINT NEATLY)

STUDENT’S NAME                                            Student ID #:                                                               

CAMPUS ADDRESS:                                                     PHONE:                                                           

DATES OF FIELD EXPERIENCE:                                                                                                          

HOME ADDRESS:                                                                                                                                

                                                                                                                                                           

* * *THE FOLLOWING QUESTIONS PERTAIN TO THE COOPERATING SCHOOL* * *

SCHOOL NAME:                                                                                                                                  

SCHOOL STREET ADDRESS:                                                                                                              

SCHOOL CITY, STATE & ZIP CODE:                                                                                                    

SCHOOL PHONE NUMBER:                                          PRINCIPAL’S NAME:                                       

SUBJECT AREA                        GRADE LEVEL:             SPED STAND-ALONE                          

TEACHER REQUESTED:                                                                                                                       

* * * * * * DO NOT WRITE BELOW THIS LINE * * * * * *

NOTES: