2010-2011 Field Experience Placement Request Form

Welcome to the Field Experience Placement Request Form. Please complete the following questions, which will take about 10 minutes. The Practicum Office will be using this information when making your field experience placements, so please be as accurate as possible. Thank you.

Field Experience dates for 2010-2011 are as follows:

Field Experience 1 - Sept. 7-10, Oct. 8-29, 2010
Field Experience 2 - Nov. 26 - Dec. 17, 2010
Field Experience 3 - Mar. 21 - Apr. 27, 2011

*
1. First Name:

First Name:

2. Middle Name:

Middle Name:

*
3. Last Name:

Last Name:

*
4. Preferred name:

Preferred name:

*
5. Gender

Gender Male

Female

6. UOIT Student ID number (9 digit number):

UOIT Student ID number (9 digit number):

*
7. Email Address: (Please use an active personal email address, rather than an address that may expire, such as a university email address.)

Email Address: (Please use an active personal email address, rather than an address that may expire, such as a university email address.) Preferred email:
Alternate email:

*
8. Please provide us with your current mailing address and telephone number(s) where we will be able to contact you and send information between now and the end of June 2010.

Street Number and Address:

Please provide us with your current mailing address and telephone number(s) where we will be able to contact you and send information between now and the end of June 2010. Street Number and Address:

*
9. City:

City:

*
10. Province/State:

Province/State:

*
11. Country:

Country:

*
12. Postal Code/Zip Code:

Postal Code/Zip Code:

*
13. Contact Number (including Area Code):

Contact Number (including Area Code): Home Telephone:
Cell Phone:

14. If you know you will be residing in a different location than the one listed above after the start of the B.Ed. Program in August 2010, please provide your contact details now (or if you will be in the same location as now - just retype your information from above). If you are moving in August, yet don't know your info yet - please give us a call when you do.

Street Address:

If you know you will be residing in a different location than the one listed above after the start of the B.Ed. Program in August 2010, please provide your contact details now (or if you will be in the same location as now - just retype your information from above). If you are moving in August, yet don't know your info yet - please give us a call when you do. Street Address:

15. City:

City:

16. Province/State:

Province/State:

17. Country:

Country:

18. Postal Code:

Postal Code:

19. Contact Number (including Area Code):

Contact Number (including Area Code): Home Telephone:
Cell Phone:

2010-2011 Field Experience Placement Request Form

*1. First Name:

2. Middle Name:

*3. Last Name:

*4. Preferred name:

*5. Gender