Fall 2020 Field Experience Form: CAMPUS August 21, 2020 F20 Field Experience Form You must complete this form by August 31 to request a field placement. Mobile Phone*BSU Email*FirstName.LastName@live.bemidjistate.edu DO NOT list @go.minnstate.edu or StarID@. 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 Middle Last CURRENT LIVING AddressList the place you live now while you are taking classes. 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. Contact the Clinical Office if you are pursuing dual licenses in Secondary and Elementary (such as Elementary Ed and 5-12 Math)K-6 Elementary Education5-12 Secondary EducationK-12 MusicK-12 Physical EducationK-12 SPEDFurther 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 (Required for 9-12 Specialty Sciences)Life Science (9-12)Physics (9-12)Chemistry (9-12)Earth & Space Science (9-12)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)ASDLDEBDList 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 3410 Science Methods-SecondaryED 4737 Content Area ReadingGEOG 3460 Social Studies Methods-SecondaryMUS 2607 Music Ed 1: IntroMUS 4607: Music ED 3: Sec MethodsMATH 3065 Algebra for TeachersHLTH 4870 Internship: Health TeachingPHED 4870 Internship: PE TeachingPHED 4514 DAPE Program PlanningOtherList other classes you are taking that have field experience attached.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 12Criminal Background Check & Drug Testing*Every school district requires a criminal background check from each candidate to be eligible to enter classrooms. Some districts also require a drug screen. I understand I will be required to submit to school district criminal background checks and drug screens to be eligible for field placements. I understand it is my responsibility to immediately notify the Clinical Director, Renae Spangler, if I expect any background checks or drug tests to reveal issues that may hinder field placements. renae.spangler@bemidjistate.edu or 218-553-4487YES
