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School of Education Clinical/Practicum Request Form

Contact Person:
Mrs. Debbie Whittingham
864.503.5520

Professor's LAST Name:  
Email Address:  
Beginning Date of Clinical:    [None] Select a Date Delete the Date   
Ending Date of Clinical:    [None] Select a Date Delete the Date  
Course Number/Title:
Preferred Location:  
Alternative Location:  
Total Hours for Clinical:  
Number of Student Placements Needed:  
Is this is a "dual placement clinical"?
          
If yes to dual placement, what two areas?    
Role of Cooperating/Host Teacher:

    

Role of Student (what must he/she complete):    
Additional Comments: