8.05.15
APPLICATION FOR (CLINICAL) INTERNSHIP
Alabama A & M University
Office of Field Experiences and School Partnerships
Directions for completing application:
Applications are submitted one semester before the intended internship. March 15 (of the previous semester) is the application
deadline for the Fall internship, and September 15 (of the previous semester) is the application deadline for the Spring internship.
Type the application. Submit to the Office of Field Experiences and School Partnerships (room 216 Carver Complex).
Semester of intended Internship:
/
Expected Date of Graduation:
(Semester)
Graduate
/
(Year)
(Semester)
Undergraduate
(Year)
Program Major
Please answer each question below, completely, and accurately.
Personal Data:
Candidate:
/
/
Title (e.g., Mr., Mrs., Ms.)
Last
Student ID No.:
/
First
Date of Birth:
/
Middle
/
/
Maiden
Place of Birth:
/
month/day/year
Marital Status:
Suffix (e.g., Jr., Sr.)
city
Number of Children:
/ state
Age(s):
Local Address:
Street/Apt/P.O. Box/Route and Box
City
State
Zip Code
Street/Apt/P.O. Box/Route and Box
City
State
Zip Code
Permanent Address:
Email address:
Permanent Telephone No.: (
Local Telephone Number: (
)
)
Mobile Telephone Number: (
)
Name of Emergency Contact Person:
Telephone Number of Emergency Contact Person: (
)
Please list any health problems that may interfere with your internship (i.e., asthma, diabetes, migraine headaches, etc.)
Language Spoken at Home:
Other Language(s) Spoken:
High School Attended:
City/State:
Colleges or Universities Attended (other than AAMU) and Degrees Received:
Academic Data:
Classification: (check one)
Graduate (5th Year)
Undergraduate (Senior)
Major:
Academic Advisor:
Departmental Chairperson:
Date of State Approved Checklist Used:
(month/day/Year)
Approved Departmental Course Substitution on file, if applicable:
Does not apply
(check one)
Yes
Overall GPA:
General Studies GPA:
Professional Studies GPA:
Teaching Field(s) GPA:
No
Have completed the required minimum 205 clock hours of field experiences, plus 7 hours of opening of the school
year and 7 hours of closing of the school year requirements and have submitted documentation to The Office of
Field Experiences and School Partnerships: (check one) Yes _
No
Have taken and passed the Praxis II exam(s): (check one) Yes _
No
Date Taken: _
Score: _
Subject Area: _
Date Taken: _
Score: _
Subject Area: _
Date Taken: _
Score: _
Subject Area: _
(Attach a copy of the passed Praxis II examination scores.)
Have been fingerprinted and passed the SDE background check: (check one) Yes _
Professional Organizations (Membership, e.g., SAEA):
2
No
Internship School Placement Requests:
Directions: (Please write the name of the school(s) where the pre-clinical (methods) block was completed, or
where you are currently completing the pre-clinical field experiences.)
lst
Name of School
District
Name of School
District
2nd
Area(s) of intended certification (e.g., elementary K-6, PE P-12, Music Vocal P-12, Music Instrumental P-12,
ECH K-3, Col K-6, Col 6-12, Art P-12, Ag 6-12, FCS 6-12, Business ED 6-12, Secondary 6-12):
1st
2nd
Requests Subject(s) (if applicable):
1St
2nd
3rd
Requested Grade Level(s):
1st
2nd
3rd
3
List course(s) currently enrolled. If none, please indicate “NONE”
COURSE NUMBER AND TITLE
SEM. HRS.
List any courses left on the checklist other than courses currently enrolled in and the internship. If none,
please indicate “NONE”
COURSE NUMBER AND TITLE
SEM. HRS.
List any deficiencies including D’s, F’s, I’s. If none, please indicate “NONE.” (Do not include course(s)
currently enrolled)
COURSE NUMBER AND TITLE
GRADE
(List D’s, F’s, I’s)
4
SEM. HRS.
Name of Candidate:_
Banner I.D. No.:
Candidate’s Signature:
Date:
Name of Advisor:
Date:_
Advisor’s Signature:_
Date:_
Chairperson’s Signature:_
Date:_
Eligibility Assessment: (completed by candidate) and advisor and signed by both candidate and advisor)
Undergraduate
Requirement
met
HAVE MET THE FOLLOWING REQUIREMENTS
(Check Met or Not Met)
1.
Have record audit checklist from academic advisor
3.
2. Have been admitted to Teacher Education
Date
Grade Point Average of 2.50 in four areas: (Overall,
Undergraduate
Requirement
Not met
Graduate
Met
Graduate
Not
Met
NA
NA
General Studies, Professional Studies and Teaching Field) for
undergraduate and grade point average of 3.0 in three areas
(overall, professional studies, and teaching field for graduate)
4.
5.
6.
7.
8.
Have approved course substitution forms for
any courses taken at another university or any
courses substituted
Grade of “C” or better in ENG 101, ENG 102,
Professional Studies and Teaching Field
Courses if undergraduate
Have earned less than one C’s in graduate
program if graduate candidate.
Have removed I’s, D’s, F’s, if not please list
course(s) below:
NA
Have taken all Praxis II tests and passed prior to
internship (Effective Fall 2006). If not, please list
the tests that are not passed:
5
NA