Clinical/Practicum Request Form

School of Education Clinical/Practicum Request Form

Professor's Last Name

Email Address

Beginning Date of Clinical

Ending Date of Clinical

Course Number / Title

CRN #

Preferred Location

Alternative Location

Total Hours for Clinical

Number of Student Placements Needed

Is this a "dual placement" clinical? Yes No

If yes to dual placement, what two areas?

Role of Cooperating/Host Teacher

Role of Student (what must he/she complete)

Additional Comments

Word verification An error has occurred while getting captcha image