Person requesting practicum placement

First name:

Last name:

Address:

City: State: Select AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY Zip:

Phone (day):

Phone (evening):

Email: PSU ID:

Prerequisite work

Completion of 12 credits of ReadOregon courses in the four thematic areas listed below are a prerequisite for the Practicum.

Please list the term completed and grade for each of the pre-requisite courses (if you are currently taking any courses, just list the term):

Timeframe
(term you want to do practicum)

Term: Fall Winter Spring

Year:

Placement preferences

Age level: (Must match teaching license levels of authorization)

ECE Elementary Middle School High School

Check here if you need a placement

Preferred School and/or District:

I understand that before I can be considered for placement, I must:

• Submit proof of fingerprint clearance to the field placement office.
  Fax: 503-725-8475
• Forward an electronic resume in Word format to: fieldplacement@pdx.edu

Check here if you plan to do practicum in your own classroom/school

Practicum Supervisor:

(Principal, Title I Teacher, District Title I, Endorsed Reading Specialist)