Fall 2019 Practicum Request Form June 1, 2019 Please complete this field experience request form so we can place you in a way that suits your schedule and interest areas. This survey reflects field experience needed for which semester?*Fall 2019Mobile Phone*BSU Email*All communication from the Clinical Office is directed to your @live.bemidjistate.edu address. Please check your email frequently. BSU ID #*8-digits. NOT your StarIDName* First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What is your INITIAL area of licensure?*Choose one.K-6 Elementary Education5-12 Secondary EducationK-12 (Music or Physical Education)Further define the license(s) you are pursuing.*You may select more than one license by holding the Control key (+CNTRL) or "Command"down while you scroll through the list. For example, you may choose Elementary and PrePrimary. Or Physical Education and Health. (Use COMMAND key on a Mac)Elementary (K-6)PrePrimary (Age 3-PreK)MS Math (5-8 Endorsement)MS Social Studies (5-8 Endorsement)MS CommArts & Literature (5-8 Endorsement)MS Science (5-8: Optional for K-6, Required for 5-12 Specialty Sciences)Life Science (5-12)Physics (5-12)Chemistry (5-12)Earth and Space Science (5-12)Math Education (5-12)Social Studies Education (5-12)English Education (5-12)Health Education (5-12 Stand-alone or K-12 Endorsement)Physical Education (K-12)DAPE (K-12 Endorsement)Music (K-12 Instrumental & Classroom)Music (K-12 Vocal & Classroom)ASDLDEBDSpanishTechnical ArtsAre you an UNDERGRADUATE student or a GRADUATE student?*Undergraduates are pursuing a 4-year degree/license and must work with the CAMPUS Clinical Office and/or BSU faculty to secure their field placements. Graduate students have a 4 year degree and may already be licensed teachers working in schools. (Attention DAPE students: Choose GRADUATE if you have already notified Sherry Holloway that you will secure your own placement, even if you are taking the DAPE course at the undergraduate level.UndergraduateGraduateAs a Grad student, list the classes you are taking.You may select more than one class by holding the Control key (+CNTRL) or "Command" key down while you scroll through the list.ED 3/5201 Language Arts 1ED 3/5410 Secondary Science MethodsED 3/5417 Teaching & Learning in MSED 4/5737 Content Area ReadingHLTH 4/5970 Internship: PE TeachingPHED 4/5514 DAPEPHED 4/5515 DAPE TeachingSPED 5600 Study of Learner Special NeedsSPED 6608 Reading DifficultiesOTHERIf they were not listed above, please list other Ed classes you are taking that require field experience in this space.Please describe your Grad Student situation.*Are you a GRAD student in the Education Program and pursuing an ED license or are you a GRAD student simply taking an ED-related course for credit? The third option applies only to DAPE students that are securing their own placements.I'm in the BSU ED Program and I'm pursuing an ED LicenseI'm just taking this course for credit.I'm in the DAPE Cohort and special circumstances apply to my situation.OtherPlease define your understanding of your field placement situation.*Most graduate-level classes hold the expectation that the grad student will secure their own field placement. Please communicate your placement information on this survey and to your instructor. I understand that it is my responsibility to secure my own field placement and I have listed that information below.I am unsure about this issue and I need to communicate more with my course instructor.List details of the placement you have arranged to complete your field experience for your graduate course(s).List ISD #, School Name, Host Teacher, Grade Level, Subject AreaList all the courses you are taking this semester that require field experience.*You may select multiple courses by holding the Control key (+CNTRL) or the "Command" key down while you scroll through the list.The BLOCK (3203, 3221, 3222, 3240)ED 3100 Intro/Foundations of Public School EdED 3201 Language Arts 1ED 3202 Language Arts 2ED 3350 PedagogyED 3670 Early ChildhoodED 4737 Content Area ReadingHLTH 4970 Internship: Health TeachingPHED 4970 Internship: PE TeachingED 3417 Teaching & Learning in MS (offered FALL)ENGL 3550 Teaching Engl & Comm (offered FALL)MUS 2607 Music Ed 1: Intro (offered FALL)MUS 4607 Music Ed 3: Seconodary EDED 3208 Reading in MS (offered SPRING)ED 3410 Secondary Science Methods (offered SPRING)ED 3440 Math Methods Secondary (offered SPRING)GEOG 3460 Teaching Soc St in MS & HS (offered SPRING)MUS 3607 Music Ed 2: Elementary Methods (offered SPRING)PHED 4514 DAPE Teaching (offered FALL)PHED 4515 DAPE Teaching (offered SPRING)List the grade levels in which you have already had field experiences*You may select multiple grade levels by holding the Control key (+CNTRL) or the "Command" key down while you scroll through the list.NONEPreprimaryKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12If you have had previous field experience, please list the school(s) where you were placed.*You may select multiple schools by holding the Control key (+CNTRL) down while you scroll through the list.NONEBemidji Elementary SchoolsBemidji Middle SchoolBemidji High SchoolBI-CAP Head StartBagley SchoolsBlackduck SchoolsCalvary Lutheran PreschoolCass Lake SchoolsClearbrook-Gonvick SchoolsDeer River SchoolsFosston SchoolsGrand Rapids SchoolsGreenway, Coleraine SchoolsHeartland Christian AcademyLaporte SchoolsNaytahwash CharterRed Lake SchoolsRed Lake County Central SchoolsSchoolcraft Charter SchoolTrek North Charter SchoolSt. Philip’s Catholic SchoolVoyageurs Charter SchoolWalker SchoolsWhen are you available to do field experience?*Please complete this question even if you are in a class that will have designated field days, such as Foundations or "The Block." Make sure you allow for at least a 2-hour segment of time in the classroom before you select availability. You may select multiple time slots by holding the Control key (+CNTRL) or "Command" key down while you scroll through the list.AM: MondayAM: TuesdayAM: WednesdayAM: ThursdayAM: FridayPM: MondayPM: TuesdayPM: WednesdayPM: ThursdayPM: FridayPlease describe the general direction you travel from to get to the BSU campus.*The Clinical Office makes every effort to arrange a placement that reduces unnecessary driving/time for students. We do not guarantee, however, that your placement will be convenient or close to your home.I live inside an 15-mile radius of BSU.North (Such as the Blackduck or Red Lake area)East (Such as the Cass Lake or Grand Rapids area)South (Such as the Walker or Park Rapids area)West (Such as the Bagley, White Earth, or TRF area)Do you have reliable transportation?*It is your responsibility to get to your field placement: even if you have to car pool, take a cab or bus, bike, or drive several miles.YESNOAre you willing to carry passengers in your vehicle?*Let us know if you are willing to carry other students in your vehicle that are scheduled at the same time and school .YESNOPlease tell us if you feel that you must be placed within walking distance of the BSU campus.*Sometimes there can be accessibility issues or other circumstances that necessitate a placement very near campus. If this is the case, and you request a placement within walking distance of BSU, you must speak with the Director. I request a placement within walking distance of BSUThis is not an issue for me.Please note any special considerations below.Use this space to tell us if you have any concerns or if the survey tool did not work or you had a survey submission problem. Thank you!
