Field Experience Placement Application
College of Education
Office of Field Services
Select Placement Area:
Select Semester/Year:
___ Fall 20__________
___ Spring 20________
_____ Mobile _____ Chickasaw City _____ Satsuma City
_____ Baldwin _____ Saraland City
_____ Out of Area (n/a for K6 Teacher Ed)
PHOTO
REQUIRED
Taken by OFS
JAG #: J00 ___________________ Social Security #: ____________________________ Date of Birth: __________________
Applicant Name ___________________________________________, ____________________________ _________________
Last
First
Middle
Local Address – This address is used to determine school placements only and does not affect your address with the University
____________________________________________________
_____________________________
Street Address
City
Cell Phone (_____) ____________________________________
______
________
State
Zip Code
Home Phone (_____) _______________________________
Email Address ________________________@jagmail.southalabama.edu (Only USA email address will be used for COE communications)
SELECT MAJOR:
Undergraduate:
Alternative Masters:
Masters/Class B Certification:
_____ K-6 Teacher Education (Elementary/SPE)
_____ 6-12 English/LA
_____ 6-12 Gen Science
_____ 6-12 Health
_____ 6-12 Mathematics
_____ 6-12 Social Studies
_____ 6-12 Special Ed Collaborative:
___ English/LA ___ Gen Science
___ Math
___ Social Studies
_____ P-12 Physical Education
_____ P-3 Early Childhood Education
_____ K-6 Elementary
_____ K-6 Special Ed Collaborative
_____ 6-12 English/LA
_____ 6-12 Gen Science
_____ 6-12 French _____ P-12 French
_____ 6-12 German _____ P-12 German
_____ 6-12 Spanish _____ P-12 Spanish
_____ 6-12 Mathematics
_____ 6-12 Social Studies
_____ 6-12 Special Ed Collaborative
_____ P-12 Art Education
_____ P-12 English for Speakers of Other
Languages (ESOL)
_____ 6-12 English/LA
_____ 6-12 Gen Science
_____ 6-12 French
_____ 6-12 German
_____ 6-12 Spanish
_____ 6-12 Math
_____ 6-12 Social Studies
Regular Masters/Class A:
_____ K-6 Special Ed Collaborative
_____ 6-12 Special Ed Collaborative
_____ P-12 English for Speakers of Other
Languages (ESOL)
_____ Opening School Experience Only
FIELD COURSE:
Please indicate course(s) for which this field experience will apply: __________________________________________________
APPLICATION CONTINUED …
1/6/2015
CHILDREN/RELATIVES:
If you have any children/relatives in a local school district, please complete the following:
School District: _____ Mobile _____ Baldwin _____ Chickasaw _____ Saraland _____ Satsuma
School Name(s) & Grade(s): ___________________________________________________________________________
IN OWN CLASSROOM:
If you are currently employed as a teacher and will fulfill this requirement in your own classroom, please complete the
following:
School Name: _______________________________________________________________________________________
Principal’s Name: ____________________________________________________________________________________
Grade/Subject: ______________________________________________________________________________________
The following are REQUIRED for field placements:
•
•
•
•
•
Digital photo taken in OFS at the time of application for first field experience
Maintain Teacher Candidacy (UG only)
Maintain clear background status
Maintain current Professional Liability Insurance coverage (n/a if In Own classroom)
Registration of appropriate field experience course. Completing this application does not register you for your
classes.
* Students will receive placements only in Mobile and Baldwin counties and Saraland and Satsuma City. Please note if you
need north/south Mobile or Baldwin county. We will try to accommodate you, but cannot guarantee a placement near your
home.
* If you are taking your tier/methods/practicum course in the fall semester, you will be participating in an Opening of School
Experience which will require that you begin school when the teachers do. This may be a week or more before classes begin at
USA. Students taking tier/methods/practicum courses in the spring semester will participate in the Opening of School
Experience in the fall with student teaching.
COMMENTS: _____________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
1/6/2015