EmailMe Form - Field Experience Placement Form

Wartburg Student Name: *

Prefix First Last

Email: *

Hometown
(Example: Waverly, IA) *

List Major(s), Minor(s), and Endorsement(s): *

If music major, select area:

Cell Phone: *

### - ### - ####

Preferred Grade Level Placement: *

Preferred Content for Placement: *

(Elem, SpEd, Math, Sci, etc.)

Do you have transportation? (Remember, not every placement can be local, there are just not enough options near campus. Car pooling may be necessary and will be your responsibility to work out.)

Yes

No

Field Experience Applying For - course # and corresponding field experience # is listed. (Please complete separate form for each field experience) *

PREVIOUS PLACEMENTS

Placement 1 (school, grade, number of hours):

List school, grade, number of hours

Placement 2 (school, grade, number of hours):

List school, grade, number of hours

Placement 3 (school, grade, number of hours):

List school, grade, number of hours

Placement 4 (school, grade, number of hours):

List school, grade, number of hours

Have you had a 25-hour diverse placement? *

Yes

No

Some schools that meet this requirement include: Waterloo, Cedar Falls, Charles City, Hampton-Dumont, Oelwein, Wartburg West, and New York City

Have you been placed in an urban setting yet? *

Yes

No

These schools meet this requirement: Waterloo, Cedar Falls, New York City, Wartburg West

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 at a private/parochial school? *

Yes

No

Example: St. Paul's in Waverly or Columbus High School in Waterloo

Additional Comments for Placement Coordinator:

Date of form completion:

MM / DD / YYYY