Vacca Office of Student Services
304 White Hall ~ (330) 672-2870
DEAF RESIDENTIAL SCHOOL ONE-WEEK FIELD EXPERIENCE
APPLICATION & STUDENT INFORMATION FORM
Please return Application and attached Student Information Form to Debbie Dotson - 304 White Hall
♦ Name ______________________________
_________________________
First
Student ID# _____________________
Last
♦ Current Address: __________________________________________________________________________________
Street
City
State
Zip
♦ Phone#_________________________________ Other# _________________________ Email ________________________
(Area Code)
Number
(Area Code)
Number
DEGREE/PROGRAM IN SPECIAL EDUCATION:
□
CONCENTRATION AREA:
DEAF EDUCATION
(kent.edu) Only
□ ASL INTERPRETING
SEMESTER APPLYING FOR:
FALL SEMESTER:
Choose One:
*Applications for Fall Semester are due by; “FIRST FRIDAY in MAY.”
□ December (Week before Christmas)
SPRING SEMESTER:
Choose One:
□ January (First 2 weeks in January)
*Applications for Spring Semester are due by; “FIRST FRIDAY in November.”
□ March (KSU Spring Break)
□ May (Week after finals)
______________________________________________________________________________________________________
DEAF SCHOOL PREFERENCES: *Please indicate 3 choices that would assist our office in finding placement.
♦ (1) __________________________________________________________________________________________
♦ (2) __________________________________________________________________________________________
♦ (3) __________________________________________________________________________________________
*Please be advised that preferences are not guarantees and we will select one of your 3 choices for initial
placement. If your three choices are not available, we will attempt to locate another school that is accepting
students. All placements and schedules are final upon confirmation and no changes can be made.
________________________________________________________________
Student Signature
____________________________________
Date
*Please return Application and attached Student Information Form to Debbie Dotson - 304 White Hall
One-Week Field Experience at a Deaf Residential School
STUDENT INFORMATION FORM
Note: This form Must be Typed and Completed Fully and Accurately
PERSONAL INFORMATION:
Name: _______________________________________________________________________________
(First)
(Last)
Address: ______________________________________________________________________________
(Street Address)
(City)
Phone: _________________________________
(State)
Zip
Cell Phone: __________________________________
E-Mail: (Kent.edu) Only. _____________________________________________________________________
In an emergency notify: ___________________________________ Phone:________________________
EDUCATION:
Degree/Program: ______________________________ Concentration Area:______________________________
Cumulative GPA: ___________
Anticipated Graduation Date/Year: ________________________________
Courses taken in the program area: ______________________________________________________________
University Activities/Interests/Hobbies Engaged in and Honors Earned: _________________________________
___________________________________________________________________________________________
FIELD EXPERIENCE: Prior field experiences taken in program area.
RELATED WORK EXPERIENCE:
___________________________________________
Student Signature
____________________________
Date
I:\oce\FieldExperience\Deaf Residential Application&Student InformationForm.doc.Rev. 2/14
PART III
Statement of Responsibility and Approval
I understand that I will assume all of the expenses, except those specifically identified as the
responsibility of Kent State University, that occur during my participation in this out-of-state
placement.
The university will not be held responsible for any medical bills during my placement. I agree to
assume all such costs.
Furthermore, I release the university from all claims of damages that may arise out of or in
connection with participation in or transportation to and from this placement.
[Print] Name of Student Teacher
____________
Signature of Student Teacher
_______________________
Date
NOTE: Upon your return to Ohio, FBI clearance and BCII background checks will be
required with your application for Ohio licensure packet (even if you are an Ohio resident).
PART IV
Parent/Guardian
NOTE: If the student is identified as a “dependent” under any insurance provider for the
parent/guardian, then the parent/guardian signatures are required. If the ‘student’ is fully independent
and legally emancipated; providing their own insurance and covering their own liabilities, the student
may sign on the appropriate line below.
I, the undersigned parent/guardian of _____________________________ do acknowledge
having received information about this out-of-state placement and do consent to his/her
participation in the program. It is understood that all expenses related to this placement are the
responsibility of my son/daughter.
The university will not be held responsible for any medical bills during the period of student
teaching out-of-state. The undersigned agrees to assume all such costs.
Furthermore, I release the university from all claims of damages that may arise out of or in
connection with participation in or transportation to and from this out-of-state placement.
_____
[Print] Name of Parent or Guardian
_____
Signature of Parent or Guardian
_______________________
Date
(OR)
I, the designated Kent State Student, confirm by my signature that I am a fully independent and
legally emancipated individual, and I am fully responsible for my own liabilities.
___________________________________________
________________________
Signature of Student
Date
_______________________________________________
PRINTED Name of Student
PART V
Medical Insurance
I, (print full name) ________________________________________________ verify that I have
medical insurance as follows:
_____________________________________________________________________________
Name of Insurance Company or Agency
________________________________________________
Policy Number
Signature:
___________________________________________
Social Security #:
___________________________________________
Date:
___________________________________________
====================================================================
NOTE: It is the student teachers responsibility to verify that out-of-state coverage is
included in his/her medical policy. Most out-of-state medical expenses are expected to be paid
for at the time of service. The student teacher will need to check with his/her insurance provider
regarding how to file for reimbursement upon return to Ohio.
The student teacher will be required to complete a specific state’s background check prior
to leaving Ohio or upon arrival in that state. The student teacher will contact the specific
school for details about the background check. Housing and transportation are the student
teacher’s responsibility. The student teacher should maintain a 3.0 GPA.
**Revised 6/15