Field Experience/Practicum Request Form

I understand that a valid, current, Missouri background check must be completed and on file with the Hannibal-LaGrange University Education Division before I can begin completing field experience hours in the classroom.*
- I understand.
I understand I am responsible for the fee associated with the background check.*
- I understand.
I understand that I will have to complete student teaching in a different school building/district if I have completed all of my field experience hours in the same school building/district (depending on size of district).*
- I understand.
Name*
First Last
HLGU Student Email*
Cell Phone*
HLGU Advisor's Name*
Campus*
Undergraduate Certification Area*
Master's Certification Area*
Select a course name and number from the following list.*
- Field Experience I (EDU 100) - 20 hours
- Field Experience I (EDU 100) ONLINE
- Field Experience II (EDU 200) - 20 hours
- Field Experience II (EDU 200) ONLINE
- Field Experience III (EDU 300) - 22.5 hours
- Field Experience IV (EDU 400) - 22.5 hours
- Content Area Practicum (EDU 301) - 45 hours
- Infant/Toddler Practicum (ECE 201) - 40 hours
- Pre K/Kindergarten Practicum (ECE 321) - 40 hours
- Literacy Practicum (EED 453) - 40 hours
- Literary Practicum (EED 453) ONLINE
- Math Practicum (EED 321) - 30 hours
- Math Practicum (EED 321) ONLINE
- Master's Level Field Experience I (EDU 5901) - 20 hours
- Master's Level Field Experience II (EDU 5902) - 20 hours
- Master's Level Field Experience III (EDU 5903) - 45 hours
EDU 5901, 5902, 5903
Your Area of Study
- Early Childhood
- Elementary
- Secondary
Select a Grade Preference
Select a Subject Area
EDU 100
Your Area of Study
- Early Childhood
- Elementary
- Secondary
Select a Grade Preference
Select a Subject Area
EDU 200
Your Area of Study
- Elementary
- Secondary
Select a Grade Preference
Select a Subject Area
EDU 300, 400
Secondary Education Subject Area
- Art
- Music
- PE
EDU 301
Select a Subject Area
EED 453, 321
Select a Grade Preference
Current School District Employee
An HLGU teacher candidate employed as the “teacher of record” or “paraprofessional” is allowed to complete HLGU field experiences in the school where employed. Specifics regarding grade level (and hours required in content area) will depend upon an individual’s employment duties and experience. HLGU teacher candidates not employed as “teachers of record” or “paraprofessionals” are expected to complete field experience placements (including student teaching) in more than one school.
Are you a full-time employee in a school district?*
- Yes
- No
Please briefly describe your current job duties:*
An HLGU teacher candidate employed full-time as the “teacher of record,” “teaching assistant,” or “paraprofessional” is allowed to complete HLGU field experiences in the school where employed. Specific classrooms and grade levels will depend upon an individual’s employment duties and experience. HLGU teacher candidates not employed as described above are expected to complete field experience placements in more than one school. Note: Only students employed as “teacher of record” or “teaching assistant” are allowed to complete all field experiences and the student teaching semester in the same school district. “Teaching assistants” and “paraprofessionals” are not synonymous. Please see the Teacher Education Program Handbook for a clear definition of “teaching assistant.”*
An HLGU teacher candidate employed full-time as the “teacher of record,” “teaching assistant,” or “paraprofessional” is allowed to complete HLGU field experiences in the school where employed. Specific classrooms and grade levels will depend upon an individual’s employment duties and experience. HLGU teacher candidates not employed as described above are expected to complete field experience placements in more than one school. Note: Only students employed as “teacher of record” or “teaching assistant” are allowed to complete all field experiences and the student teaching semester in the same school district. “Teaching assistants” and “paraprofessionals” are not synonymous. Please see the Teacher Education Program Handbook for a clear definition of “teaching assistant.”
- I understand.
Preferred School District - First Choice
Specific Teachers may not be requested
Subject/Grade*
District*
School*
City*
State*
Preferred School District - Second Choice
Subject/Grade*
District*
School*
City*
State*
Provide information related to previous college/university field experience(s)
Field Experience I - School
Teacher Name
First Last
Grade
Select all that apply.
- Self-Contained (Elementary)
- General (MS/HS)
- CWC (class-within-a-class) (MS/HS)
- College Prep - HS
Field Experience II - School
Teacher Name
First Last
Grade
Select all that apply.
- Self-Contained (Elementary)
- General (MS/HS)
- CWC (class-within-a-class) (MS/HS)
- College Prep - HS
Field Experience III - School
Teacher Name
First Last
Grade
Select all that apply.
- Self-Contained (Elementary)
- General (MS/HS)
- CWC (class-within-a-class) (MS/HS)
- College Prep - HS
By submitting this form, you agree to the following:*
I understand that in order to enter, remain in, and exit from the HLGU Teacher Education Program, I must comply with all institutional and state requirements. My failure to comply with any institutional requirement (including HLGU student conduct regulations) or state requirement could result in my being dismissed from the program, making me ineligible to be recommended for certification. I understand that by virtue of my enrollment in teacher education courses at Hannibal-LaGrange University and by participation in various classroom activities (i.e., educational field experiences and student teaching), I may have access to records which contain individually identifiable information. The disclosure of this information is prohibited by the Family Education Rights and Privacy Act of 1974 (Buckley Amendment). I acknowledge that I fully understand that the intentional disclosure by e of this information to any unauthorized person (i.e. talking about a particular student or teacher to a friend) could subject me to criminal and civil penalties imposed by law. I further acknowledge that such willful or unauthorized disclosure could constitute just cause for disciplinary action and/or removal from the teacher education program by Hannibal-LaGrange University's Teacher Education Division regardless of whether criminal or civil penalties are imposed.
- I agree to the above confidentiality statement.

EDU 5901, 5902, 5903

EDU 100

EDU 200

EDU 300, 400

EDU 301

EED 453, 321

Current School District Employee

Preferred School District - First Choice

Preferred School District - Second Choice

Provide information related to previous college/university field experience(s)