Form A

University of Kentucky Field Experiences Office
104 Taylor Education Building
Lexington, KY 40506-0001
Telephone: (859) 257-1857

REQUEST FOR FIELD EXPERIENCE PLACEMENT
for Out-of-County or Private School Placements

Teacher Training Institution: ______________________________
Student's Name: ______________________________________ ID#: _____________________
E-mail: _____________________________________________ Phone: ____________________
EDP Instructor: __________________ Phone: ______________ Course: _______ Section ______
Teaching Major(s) / Area of Emphasis Certification: ______________________________

Provide information pertaining to the nature of this field placement experience.
Requirements:  
Number of visits ________ ___ to observe
Length of each visit ______ ___ to assist
Times available ______________ morning ___ to teach whole class
                        ______________ afternoon ___ to tutor individual or small group
   
Note to the Teacher: The student has been instructed to register in the school office and visit your classroom as indicated above. If this is not convenient, please contact the student directly.

ASSIGNMENT

  
School _______________________________________ Date: ______
Teacher_______________________________________ Date: ______
Principal ______________________________________ Date: ______
EDP Instructor _________________________________ Date: ______
   

NOTE: Students must secure signatures of Principal and Teacher on the first visit and bring original form to 104 Taylor Education Bldg.