MEd Field Experience Form - Hannibal-LaGrange University

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 I will not be approved to complete all HLGU field experience placements in the same district/school.*

I understand.

Name*

First Last

HLGU Student Email*

Cell Phone*

HLGU Advisor's Name*

Certification Area*

Select a course name and number from the following list.*

Current School District Employee

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.”

I understand.

Preferred School District - First Choice

Specific teachers may not be requested

District*

School*

City*

State*

Preferred School District - Second Choice

District*

School*

City*

State*

Provide information related to previous administration observation experience(s)

School 1

Administrator's Name

First Last

Grade Levels

Select all that apply.

Self-Contained (Elementary)
General (MS/HS)
CWC (class-within-a-class) (MS/HS)
College Prep - HS

School 2

Administrator's Name

First Last

Grade Levels

Select all that apply.

Self-Contained (Elementary)
General (MS/HS)
CWC (class-within-a-class) (MS/HS)
College Prep - HS

School 3

Administrator's Name

First Last

Grade Levels

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.