CSB/SJU Student Request for Field Placement

Name

CSB/SJU Email address

Phone number

Placement Semester

For which course do you need a placement?

I give the CSB/SJU Education Department permission to share my email address and/or phone number with potential cooperating teachers and schools.

	Yes
	No

What is your intended licensure area?

Ex., k-6, 7-12 Social Studies

With which grade levels have you already had practicum experiences, if any?

Ex., grades 1 and 3

Transportation Needs

	I have access to a car.
	I do not have a car.

If you attended an elementary, middle, or senior high school within a 30-mile radius of CSB/SJU as a k-12 student, please list those schools below.

If you have any special practicum-related needs, please consult with your instructor.

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