Clinical Placement Student Information Form fill in blank

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					Course & Section #: Click here to enter text.
Instructor: Click here to enter text.

                               Clinical Placement Student Information Form
Please note:
 Students should complete a clinical placement student information form for EACH class they are
    enrolled in that has a clinical component and submit to their instructor.
 All clinical placements are coordinated within a 40 mile radius of Graves Hall and are coordinated in
    public accredited schools, unless a placement cannot be identified.
 All clinical placements are made within the typical school day (7:30 am – 3:15 pm).
 Before students can report to their assigned clinical placement, they MUST have a Letter of
    Suitability OR verification of a background check and clearance from the Alabama Department of
    Education.

PLEASE PRINT
Full Name (as it appears on class roll): Click here to enter text.
CWID: Click here to enter text.
Major: Click here to enter text.
Email Address: Click here to enter text.
Local Street Address (include city & zip code): Click here to enter text.
Click here to enter text.
Phone # (include area code if # is not a local call): Click here to enter text.
Place of Employment & Phone #, if applicable: Click here to enter text.
         Click here to enter text.
In case of emergency, whom should we notify (please include phone # and relationship to contact) :
         Click here to enter text.
Past Clinical Experiences (Include School Name, Grade Level, and Subject, if applicable)
Click   here   to   enter   text.
Click   here   to   enter   text.
Click   here   to   enter   text.
Click   here   to   enter   text.
Click   here   to   enter   text.

Special Request (Please remember that the Office of Clinical Experiences is responsible for ensuring
that all students have placements in diverse settings prior to being recommended for certification.):
Click   here   to   enter   text.
Click   here   to   enter   text.
Click   here   to   enter   text.
Click   here   to   enter   text.
Click   here   to   enter   text.

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Please indicate class & work schedule in table below. You MUST include course # and meeting times.

Monday              Tuesday             Wednesday            Thursday            Friday
For example:        For example:        For example:         For example:        For example:
CSE 489             EN 300              CSE 489              EN 300              CSE 489
(8:00-9:50)         (9:30-10:45)        (8:00-9:50)          (9:30-10:45)        (8:00-9:50)
For example:                            For example:                             For example:
BER 450                                 BER 450                                  Work
(1:00-2:15)                             (4:00-5:15)                              (1:00-6:00)
For example:                            For example:
CSE 479                                 CRD 412
(5:00-7:50)                             (5:30-8:20)
Monday              Tuesday             Wednesday            Thursday            Friday
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