Field Experience Proposal Form
Student Name:_________________________________________
Valencia Student ID Number: V _________________________
I have received a request from ____________________________ to host a Directed Field
Experience. I agree to assist and supervise the above named student. I understand that I
am welcomed to contact Dr. Molly McIntire anytime during this field experience at (407)
582-5473 with any issues or concerns regarding this field experience.
__________________________________________
Supervising Teacher Name
__________________________________________
Supervising Teacher Signature
__________________________________________
Supervising Teacher Email
__________________________________________
Grade Level
__________________________________________
Date
__________________________________________
Host School Name
__________________________________________
Host School Address
___________________________________________
___________________________________________
Host School Phone Number
___________________________________________
Principal Name
___________________________________________
Best Time to Contact
Comments: