For which semester are you requesting a field placement? *
- Select Option Fall Winter

Practicum Area *
- Select Option EDI 341 with infants and toddlers EDI 441 with preschoolers

Practicum Area *
- Select Option EDS 470 with children with disabilities

First Name *

Last Name *

Former Name(s)

G-number *

Date of Birth *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970

GVSU Email *

Phone *

Local Address *

Home/Permanent Address *

Placements will generally be completed within a 50-mile radius of the Allendale campus. Placements can be made outside this area if deemed appropriate for suitable supervision and effective use of Grand Valley State University resources. Your preferences are not guaranteed; however, the Education program faculty will determine the appropriateness of placements based on student training needs and placement procedures established with school authorities. Students are not to seek their own placements.

General location from which you will commute during this placement. Local address will be used if left blank.

While the college makes all placements, if you have a site in mind we might consider, please list below.

While the college makes all placements, if you have a site in mind we might consider, please list below.

Please include any special considerations regarding field placement accommodations (example: Will need placement along bus route.)

Grand Valley State University’s College of Education and Community Innovation has strict requirements for students pursuing teacher certification at our university. Students who have certain misdemeanors, multiple misdemeanors or a felony(s) may be denied admission to the College of Education and Community Innovation. If admission is granted, a field placement might not be found due to partner policies and procedures. If a student is recommended to the Michigan Department of Education for Teacher Certification, the conviction could have an adverse effect on being granted a teaching certificate. Be advised, if a teaching certificate is granted with convictions or infractions, it does not guarantee employment.

THE BELOW QUESTIONS DO NOT PERTAIN TO EXPUNGED AND/OR DEFERRED CHARGES

Have you ever been convicted of a felony or misdemeanor? *
- Select Option No Yes

Which have you been convicted for? *
Felony
Misdemeanor

Do you have any charges pending? *
- Select Option No Yes

Have you ever had a teaching/administrator certificate or school counseling/psychologist license denied, revoked or suspended? *
- Select Option No Yes

Are you currently employed by a school district? *
- Select Option No Yes

What was the specific offense(s)? *

What was the date of the conviction(s)? *

What was the conviction(s)? *

In what city and state did the offense(s) occur? *

In what court(s) was/were the conviction(s)? *

What was the case number(s)? *

Please obtain and attach photocopies of court documentation (i.e., register of action, summary or "Judgment of Sentence") from the court proceedings and any related background information that you consider important.

If you have any felony or misdemeanor charges, and it is a NEW charge since you turned in your last application, please attach pertinent information regarding the NEW issue to this application. If you turned in this information previously, we do not need to have the paperwork again.

If charged with a misdemeanor and/or felony after submission of this application, I will notify immediately the Office of Certification and Accreditation at (616) 331-6650 and will provide copies of court documents.

If you have questions about convictions and reporting this information please contact the Office of Certification and Accreditation at [email protected].

By initialing below, I confirm that I have answered these questions to the best of my ability. *

Pursuant to federal law, the Family Educational Rights and Privacy Act of 1974, as amended, (FERPA) requires, subject to specific exceptions, Grand Valley State University to have written permission from its students before releasing any information from a student’s educational record.

The academic requirement of Grand Valley State University’s Education programs mandates that each of its students complete field practicums. In order for field placements to be made by the College of Education and Community Innovation, it must be permitted to disclose students’ records to school districts, which are prospective placement sites for the students to complete their practicum requirements. Student records include all educational records maintained by the University on behalf of the student. Further, post students’ graduation from Grand Valley State University, we are frequently asked to provide employment recommendations. In order for these recommendations to be made by the College of Education and Community Innovation, we also need to have permission granted to disclose student records maintained by the University on behalf of the student. In recognition of the above, applications for admission into the College of Education and Community Innovation must include this signed consent to release education records.

Please read both of the following statements. By signing below, you are agreeing to authorize a representative of Grand Valley State University permission to release pertinent records regarding your education history at our institution:

• I authorize a designated representative of Grand Valley State University to release my educational records to school districts in which I may be placed for a field practicum. This consent does not require the release of such educational records, if, in its sole discretion, the University deems it unnecessary to do so, nor does the release of educational records guarantee my placement at any school district.
• I authorize a designated representative of Grand Valley State University to release my educational records to school districts in which I may be an applicant for a paid position, including but not limited to the position of teacher. This consent does not require the release of such educational records, if, in its sole discretion, the University deems it unnecessary to do so for the purpose of employment outside the University.

I acknowledge that I may review my educational records maintained by the College of Education and Community Innovation provided I submit my written request to the Dean of the College of Education and Community Innovation three (3) business days in advance and that such review will take place between 8:00 a.m. and 5:00 p.m., Monday through Friday on days Grand Valley State University is open for business. The University’s policy on the Family Educational Rights and Privacy Act of 1974, as amended, as stated in Section 209 of the Student Code shall govern all other aspects of my educational records and Live Scan results.

Grand Valley State University, its Board of Trustees, officers, employees, agents are hereby released from legal responsibility or liability for the release of such information and records as authorized by this consent form.

• I have read the above consent information and give willful consent of all its terms and conditions.
• I agree to the release of my educational records under the above detailed circumstances.

Acknowledgements

• I understand that placements, including school location and grade level, will be made in terms of programmatic needs and design, supervisory load, and the availability of placement situations within the schools within the placement radius.
• I am willing to accept the placement assignment as determined by College of Education and Community Innovation and further understand that particular interest areas and grade levels will not necessarily be accommodated.
• I understand that transportation to and from my placement assignment is my responsibility.
• I agree to report changes of name, address, telephone number and e-mail address immediately to the Office of Certification and Accreditation in the College of Education and Community Innovation.
• I agree to notify the Office of Certification and Accreditation in the College of Education and Community Innovation if I receive a placement where a relative is employed or attending school.
• I certify that the answers given in my application are complete and accurate. Failure to provide accurate information or concealment or misrepresentation of any information may result in denial of admission, field placements, recommendation for teacher certification, or recommendation for additional endorsements.

I have read all the information above and have completed this application to the best of my ability.

Today's Date *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2024

Current resume which includes your e-mail address and references on plain white paper.
Please upload a file with the extension .doc, .pdf, .rtf, .docx, .pub, or .txt with a maximum size of 1 MB (1024 KB)

Miscellaneous Documents (if needed, can be used for court documents, etc.)
Please upload a file with the extension .doc, .pdf, .rtf, .docx, .pub, or .txt with a maximum size of 1 MB (1024 KB)