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* 1. First/Last Name

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* 2. CWID

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* 3. Tech Email

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* 4. Cell Phone(write like this...000-000-0000)

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* 5. Certification Area/Major

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* 6. Practicum Course:

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* 7. Name of Elementary School(s) you attended.

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* 8. If you have already completed any previous field placements, list here. If this is your first math practicum, just state NO PREVIOUS PLACEMENTS.

Examples:
Reading - 3rd - Smith - _____ Elementary School - Lincoln Parish
Math - 5th - Jackson - Crawford Elementary - Bienville Parish

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* 9. Submit your class schedule here in the comment box so we can finalize your placement. (Ex.: T/R 8-10 class, T/R 2-4 class, M/W/F 9:30-10:45 class.) If ANYTHING changes in this schedule, contact Dr. Vessel (avessel@latech.edu) immediately.

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* 10. When do you have a block of time daily for practicum. Check all that apply. If you do not have 1 block open all week, you may want to review your current schedule with your advisor to see if any sections can be changed. The BEST schedule is being in the classroom for math or science/social studies DAILY. You are shortchanging yourself if you cannot see the day to day learning taking place in the classroom.

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* 11. I understand that in order to have a placement finalized and ready, it is important to check my Tech email regularly, even during break, in case the CRRC needs to reach me. Providing the date of this survey submission is your evidence of understanding this statement.

Date

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* 12. Please note if you would prefer a placement in another town besides Ruston. We love giving you opportunities in other districts!

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