EmailMeForm
Field Experience Placement Information Form
Wartburg Student Name:
*
Prefix
First
Last
Email:
*
Hometown
(Example: Waverly, IA)
*
Cell Phone:
*
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Do you have a car? (Not every placement for every field experience can be local, there are just not enough options near campus. Car pooling may be necessary.)
*
Yes
No
Social Security Number:
Check for your Major:
*
Elementary Education
Secondary Education
PE
Music Education
If music major, select content area:
Please select
Instrumental
Vocal
Music Therapy
Please list Endorsements:
Preferred Grade Level Placement:
*
Preferred Content for Placement:
*
(Elem, SpEd, Math, Sci, etc.)
Field Experience Applying For - course # and corresponding field experience # is listed. (Please complete separate form for each field experience)
*
ED 100/181 Foundations of American Education
ED 214/284 Intro to Mild & Moderate
ED 215 Psychology of the Exceptional Learner
ED 230/282 Teaching in the Secondary Schools
ED 315/383 Education Psychology
ED 321/385 Reading in the Elementary School
ED 324/382 Remedial Reading
ED 355/481 Early Childhood Practicum
ED 361/384 Middle School Curriculum
ED 473 ESL FE
MA 312 Teaching Elementary Math Methods
MA 470 Math Methods
MU 209/181 Elementary Choral/Instrumental Music Methods
MU 309/281 Secondary Choral/Instrumental Music Methods
PE 252 Elementary PE Methods
PE 470 Secondary PE Methods
HE 250 Secondary Health Methods
Other
PREVIOUS PLACEMENTS:
List the last four placements that you've had, what school, city, and grade level.
Placement 1 (school, grade, number of hours):
List school, city, grade level
Placement 2 (school, grade, number of hours):
List school, city, grade level
Placement 3 (school, grade, number of hours):
List school, city, grade level
Placement 4 (school, grade, number of hours):
List school, city, grade level
Have you had a 25-hour diverse placement?
*
Yes
No
Some schools that meet this requirement include: Waterloo, Charles City, Hampton-Dumont, Oelwein, and Wartburg West. This list can change from year-to-year as the requirements are adjusted.
Have you been placed in a small, rural school?
*
Yes
No
For example: Clarksville, Aplington-Parkersburg, Denver, Dunkerton, Janesville, Sumner-Fredericksburg, Nashua-Plainfield, North Butler, Tripoli, Wapsie Valley
Have you been placed in an urban setting yet?
*
Yes
No
These schools meet this requirement: Waterloo, Cedar Falls, Wartburg West, Des Moines
Have you been placed at a private/parochial school?
*
Yes
No
Example: St. Paul's in Waverly or Columbus High School in Waterloo
Date of form completion:
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YYYY
