Intern Placement Assignment/Agreement
This page is to be completed by college and school district Staff Only:
Duval County Public Schools: Once the agreement is signed by all parties, please return this page to levertl@duvalschools.org or mail
to Lynn Levert, Building 3001, Human Resource Services, Intern Placement, Duval County Public Schools, 1701 Prudential Drive,
Jacksonville, FL 32207.
Other counties/schools: After all parties have signed the agreement, return to Field Experience, School of Education, Florida State
College at Jacksonville, 101 West State Street, Jacksonville, FL 32202, email to Roshella.Waters@fscj.edu , or fax to 357-8926.
We, the undersigned, agree that
be assigned to
Name of Student
intern at the following school during the
Spring or
Fall term.
Date
Signature or Electronic Agreement of Field Experience Facilitator
Date
Signature or Electronic Agreement of County Superintendent or Supervisor
Date
Signature of Principal
Name of School
School Phone Number
School Address (Street, City, Zip Code)
Type or Print Name of Directing Teacher
Grade/Subject
Directing Teacher E-mail Address
3+ years successful teaching
Yes
No
CET Trained
Yes
No
Date of Training
1
Florida State College at Jacksonville is a member of the Florida College System and is not affiliated with any other public or private university or college in Florida or elsewhere.
Florida State College at Jacksonville does not discriminate against any person on the basis of race, color, ethnicity, genetic information, national origin, religion, gender, marital status,
disability, or age in its programs or activities. Inquiries regarding the non-discrimination policies may be directed to the College’s Equity Officer, 501 West State Street, Jacksonville, Florida
32202 | (904) 632-3221 | equityofficer@fscj.edu.
Area(s) of Certification
Date
Signature or Electronic Agreement of Directing Teacher
Intern Information
(Name)
Last
(Address)
Street
First
Apt. #
Primary Phone Number
Sex
Maiden
City, State, and Zip code
Alternate Phone Number
Race
Student E-mail
Date of Birth
Florida Teacher Certification Exams
For each exam passed, provide the Pass Date or enter NONE. If you have not taken the PK3 Subject Area Exam or the
Professional Education Exam, provide a scheduled date or Projected Scheduled Date. All Florida Teacher Certification
Exams must be passed in order to graduate from the BS ECE program with the state of Florida.
The General Knowledge (GK) exam must be passed prior to your Internship. ____ Initial Here
Test
1.
Pass Date
Scheduled Date
Projected Scheduled Date
General Knowledge
Math
English
Reading
Essay
2.
PK3 Subject Area Exam (SAE)
3.
Professional Education Exam (PEd)
2
Florida State College at Jacksonville is a member of the Florida College System and is not affiliated with any other public or private university or college in Florida or elsewhere.
Florida State College at Jacksonville does not discriminate against any person on the basis of race, color, ethnicity, genetic information, national origin, religion, gender, marital status,
disability, or age in its programs or activities. Inquiries regarding the non-discrimination policies may be directed to the College’s Equity Officer, 501 West State Street, Jacksonville, Florida
32202 | (904) 632-3221 | equityofficer@fscj.edu.
Student Name
Initial Understanding Portfolio
The Initial Understanding Portfolio is considered an entrance requirement for the internship. You are expected to
submit all sections of the portfolio before the internship begins.
District Preference and Fingerprinting Status
*Fingerprint results do not transfer from district to district or from agency (i.e. VPK) to school district. Please contact the
field experience staff if you have questions about the process.*
Choose only one district and fingerprinting status below. I would like to intern in the following county:
Clay
Duval
Nassau
St. Johns
Other (Provide Name):
I require fingerprinting
I DO NOT require fingerprinting because I am a substitute or employee of the school district chosen
I DO NOT require fingerprinting because I was PREVIOUSLY FINGERPRINTED by the school district chosen
I understand that I will need to be fingerprinted within one month of submitting the internship application. I will contact
the Field Experience Office for fingerprinting information if I have any questions. _____ Initial Here
Placement Preferences
Note: The college, district, and school will determine the most appropriate placement for each student.
All placement decisions are final. Students should NOT call a district office concerning placement. Students will be
notified of their placement at the orientation meeting held annually at the end of November or May.
Student Name
3
Florida State College at Jacksonville is a member of the Florida College System and is not affiliated with any other public or private university or college in Florida or elsewhere.
Florida State College at Jacksonville does not discriminate against any person on the basis of race, color, ethnicity, genetic information, national origin, religion, gender, marital status,
disability, or age in its programs or activities. Inquiries regarding the non-discrimination policies may be directed to the College’s Equity Officer, 501 West State Street, Jacksonville, Florida
32202 | (904) 632-3221 | equityofficer@fscj.edu.
Special Accommodations
If you have a disability, which will require accommodations during the internship, please describe the type of disability
and specify the accommodations you will require (e.g. interpreting, physical limitations, etc.)
Special Request
If you are a current school employee, substitute teacher or a volunteer requesting a particular school, have the Principal
or Vice Principal write a short letter requesting your intern at his/her school. The letter must be submitted with your
application, not at a later date. This does not guarantee that you will be placed at the requested school; it simply
confirms a specific request.
Essay
Please complete an essay on the topic noted below. This essay will be read by school district officials, principals, and
teachers. If an essay is inadequate it may hurt your opportunity to intern at a specific school. Your essay should be
specific, concise, and include research to support your statements about teaching. Write about specific skills you
possess.
Essay Topic: Why do I want to be a Teacher?
Type Essay Below (space will be added as you type). Please single space and double space in between paragraphs:
4
Florida State College at Jacksonville is a member of the Florida College System and is not affiliated with any other public or private university or college in Florida or elsewhere.
Florida State College at Jacksonville does not discriminate against any person on the basis of race, color, ethnicity, genetic information, national origin, religion, gender, marital status,
disability, or age in its programs or activities. Inquiries regarding the non-discrimination policies may be directed to the College’s Equity Officer, 501 West State Street, Jacksonville, Florida
32202 | (904) 632-3221 | equityofficer@fscj.edu.
Student Name
Acknowledgement
I have read and understand the conditions of Internship and agree that I will fulfill the obligations of this agreement.
I understand that there can be no guarantee of placement as requested, that all internship placement decisions
are final, and agree to accept the placement assigned. I agree to abide by all policies, rules and regulations of
Florida State College at Jacksonville, the cooperating school, and district in which I am placed. I understand if I am
dismissed from my placement, I will be required to complete remediation by Florida State College at Jacksonville.
I understand if I am dismissed from my placement, I must complete remediation prior to being allowed to reenroll
in the internship in a later semester. I agree that I have one opportunity to successfully complete the internship
after remediation. If I am unable to complete the second internship, I understand that I will be dismissed from the
Bachelors in Early Childhood Education program at Florida State College at Jacksonville. I hereby give my consent
for the Office of Educational Field Experiences to release all information contained in this application to the
county, to the principal of the school(s) to which I am assigned, to my directing teacher, and to my college
supervisor.
If, for any reason, I am unable to fulfill my internship commitment, I will notify the School of Education
immediately in writing.
Signature
Date
5
Florida State College at Jacksonville is a member of the Florida College System and is not affiliated with any other public or private university or college in Florida or elsewhere.
Florida State College at Jacksonville does not discriminate against any person on the basis of race, color, ethnicity, genetic information, national origin, religion, gender, marital status,
disability, or age in its programs or activities. Inquiries regarding the non-discrimination policies may be directed to the College’s Equity Officer, 501 West State Street, Jacksonville, Florida
32202 | (904) 632-3221 | equityofficer@fscj.edu.