SHIPPENSBURG UNIVERSITY

DEPARTMENT OF EDUCATIONAL LEADERSHIP AND SPECIAL EDUCATION

APPLICATION FOR THE PRACTICUM EXPERIENCE

    PRACTICUM EXPERIENCES MUST BE ARRANGED WITH DEPARTMENT CHAIR AT LEAST ONE YEAR IN ADVANCE

NAME_______________________________________________________  STUD ID:  ___________________

ADDRESS _________________________________________________________________________________________

PHONE:  (work) ______________________________  (home) ________________________________________

EMAIL:  _________________________________________________________________________________________

  I.  Please provide information requested.

                I am applying for Practicum I during Semester ­­­______ of the 20 _____-20_____ School Year.

                Please indicate when you hope to take Practicum II.  Semester _____ of the 20____-20____ School Year.

               

               

 II.  Practicum requirements will be fulfilled at :

       _________________________________________________________________________________________

                           (building)                                                                      (district)

              Mentor _________________________________________Title _____________________________

              Address __________________________________________________Phone ____________________

III.  My home school district is

      _________________________________________________________________________________________

                                            (building)                                                                   (district)

IV.  Superintendent’s approval:

      ________________________________________________________________________________________

                                           (signature)                                                                                  (date)

Please send your completed application to:

                Department of Educational Leadership and Special Education

                Shippensburg University

                1871 Old Main Drive

                Shippensburg, PA  17257

You will be notified when your application is approved.  If you have any questions, please contact the office of Educational Leadership and Policy at (717) 477-1591.

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FOR EDUCATIONAL LEADERSHIP USE ONLY

­­­­­­­­­_________ Application Rejected                    Reason ____________________________________________

_________ Application Approved                  Intern assigned to ____________________________________

                                                                                ___________________________________________

                                                                                                Department Chair