THE APPLICATION PACKAGE MUST INCLUDE THE FOLLOWING
FIELD PLACEMENT INFORMATION
1. APPLICATION FORM: ONE COPY ONLY
 Personal ID (your address and phone number during the field placement
interval). Your email address.
 Identify Childhood or Adolescent plus the Area of Adolescent Certification
specifies, e.g. Grand Erie DSB (Haldimand area).
 1st Choice School Board should be the board supporting the high school you
attended. (Many school boards will only accept students who live in the
district & attended a high school in the board).
 Adolescent school students – if area of adolescent certification in Social
Studies, please be more specific, e.g. Social Studies (Geography).
 TODAY – COMPLETE & SUBMIT THIS FORM BEFORE LEAVING
THE MEETING.
2. STUDENT PROFILE: FIVE COPIES
 Personal ID
 Identify Adolescent School Attended
 Area of Certification: Childhood or Adolescent and Area of Adolescent
Certification.
 Professional Course Work:
 Adolescent Certification Program: List two columns – one column
Undergraduate Courses and one column D’Youville College courses. (A
sample sheet is enclosed)
1. List all undergraduate courses supporting your teachable by
course name only.
2. List all D’Youville Courses by name
 Childhood Certification Program
1. List all D’Youville Courses by name

Education Field Experience
 List any teaching related experiences / volunteer positions / work
 This sheet should be a good, clear copy (computer printed form). A
copy is sent to your faculty consultant, school board, and each
classroom consultant accepting you as a student teacher.
 Please complete the student profile on one sheet only.
DEPARTMENT OF EDUCATION
APPLICATION FOR EDUCATION FIELD PLACEMENT
UNDERGRADUATE JUNIOR PARTICIPANT/STUDENT TEACHER
POST BACCALAUREATE/GRADUATE ELEMENTARY/SECONDARY
Please Print
NAME:
MAILING ADDRESS:
STREET:
_____________________________
CITY:
_____________________________
POSTAL CODE:
_______________________
PHONE: (AREA CODE)
EMAIL:
TYPE OF PLACEMENT REQUESTED:
CHILDHOOD:______
AREA OF CERTIFICATION_____
ADOLESENCE:_____
REQUEST FOR CONSIDERATION IN PLACEMENT (You may request a
geographic area or school board, not a specific teacher or school on this form.
Canadian students will be placed in one (1) board only.
School Board
1st. Choice:
2nd. Choice:
*No student will be considered for placement until this form is completed. You will
be notified by mail as to your placement. DO NOT call the college asking for
placement location. All efforts will be made to meet your needs with regard to
location but no guarantees will be made to anyone. If deadlines are not adhered to,
a late fee can be applied and your placement options will be jeopardized. It is the
student teacher’s responsibility to provide transportation to any field experience
placement.
D’YOUVILLE COLLEGE STUDENT PROFILE
NAME:
ADDRESS:
EMAIL ADDRESS:
PHONE:
Canadian students must indicate secondary school attended:____________________________
(specialty/interest)
AREA OF CERTIFICATION:
PROFESSIONAL COURSEWORK:
EDUCATIONAL FIELD EXPERIENCE:
Field Placement Request
If you would like a specific placement, please provide the following information.
Note: This is a request and does not, in any way, guarantee you this placement.
There are many variables that must be considered.
Your Name ________________________
Major ________________
Home Phone ______________
Date ________________
Address
____________________________________________________
____________________________________________________
Check one:
Junior participant (j. p.)
Undergraduate student teacher
Graduate student teacher
Request 1
School
Address
______________________________
Phone __________
_______________________________
_______________________________
Teacher
_______________________________
Principal
_______________________________
Grade __________
Request 2
School
_______________________________
Address
_______________________________
Phone __________
_______________________________
Teacher
_______________________________
Principal
_______________________________
Grade
__________
_____
_____
_____