Fall 2013
Undergraduate Learn and Serve Field Placement Application
Please fill out all the information below. |
| Personal Information |
| Name |
|
Student Number |
|
| Local Phone Number |
|
Cell Phone |
|
| Niagara University Email |
|
Student Year |
|
| Home Address |
|
Home City |
|
| Home State/Province |
|
Home Zip/Postal Code |
|
| Education Information |
| Major |
|
If Other, Specify |
|
| Content/Subject Specialty |
|
|
|
| What is/are your area(s) of Certification (Please check all that apply) |
| |
Birth - 6 |
1 - 6 |
1 - 9 |
5 - 12 |
| |
7 - 12 |
Special Education & Childhood 1 - 6
|
Special Education & Childhood 7 - 12 |
| Is this placement for an Education Requirement? |
|
|
|
| If so, what is the Education course number? |
|
Section |
|
| Placement Information |
| Do you have your own transportation? |
|
Resident
Commuter |
| If you request transportation through L&S, you must add 30 minutes of transportation time both before and after your two hour placement. |
| Interested in Paid/One-On-One Tutoring? |
|
|
|
You are required to complete a 20-hour Learn & Serve field placement each semester. Questions regarding certification requirements should be directed to your advisor and the College of Education.
|
| Are you arranging for your own “Private Placement”? |
|
|
Most undergraduates will be assigned to tutor one day per week for two hours. If we transport you to the site, please allow 30 minutes before and after your placement for travel time. For example, if you are scheduled 10:00 to 12:00 for your placement, you will actually be scheduled for transportation at 9:30. Please check all the days you are available and indicate your time(s) of availability. Remember, the more options you offer us, the easier it will be to place you.
Also, please indicate if you need to return for a class at a particular time! Students who are setting up a “Private Placement” need not complete this section. |
|
Monday |
Times Available |
|
|
Tuesday |
Times Available |
|
|
Wednesday |
Times Available |
|
|
Thursday |
Times Available |
|
|
Friday |
Times Available |
|
| Remember: |
Elementary programs generally run from 9 AM to 3 PM or 9:30 AM to 3:30 PM
Secondary programs generally run from 8 AM to 2:30 PM
|
| Please list any special time constraints you may have, concerns or questions. |
| |
|
| Are your fingerprints on file with the NYS education department? |
|
|
| *Although NY State requires fingerprinting for all new teachers, some school districts are beginning to require fingerprinting for visitors or volunteers as well. It is highly recommended that you attend to this well before you begin your teaching assistantship. It is your personal responsibility to do so. Fingerprinting kits are available in the College of Education. |
| For Returning Students Only |
| Please indicate your previous placements to date. This information is necessary, as it will help us meet your certification requirements. YOU WILL NOT RECEIVE A PLACEMENT UNLESS THIS SECTION IS COMPLETED! |
| Please choose all that apply: |
|
|
|
| |
Elementary
Middle
High School
Community Center
Other |
| Site/School |
|
Grade Level |
|
| Site/School |
|
Grade Level |
|
| Site/School |
|
Grade Level |
|
| Site/School |
|
Grade Level |
|
*Please indicate with the grade level if it was an inclusion class.
Any student eligible for and needing accommodations because of a disability is requested to speak to Learn and Serve Niagara before the start of their field placement. |
| Verification Information |
| Image Verification Code |
 |
|
| For security purposes enter the verification code as shown |
|
| |
|
|
|
