EDU 256: SEMINAR FOR FIELD EXPERIENCE
(PHYSICAL EDUCATION)
(Middle School/Junior High AND High School)
“HOST SCHOOL DISTRICT INFORMATION FORM”
Directions for completing this form are as follows:
(1) Both your first preference and alternate preference for a NEW YORK STATE PUBLIC
SCHOOL DISTRICT are to be close to your home because you will be completing your
field experiences during the designated College vacation. If your permanent residence is
out-of-state, then you must obtain temporary housing in New York State with relatives or
friends.
(2) The dates for the field experiences are as follows:
(a) First five days= Monday, January 5, 2015-Friday, January 9, 2015
(b) Second five days= Monday, January 12, 2015-Friday, January 16, 2015
NOTE: The foregoing dates do not allow for any make-up day(s) if the host district’s
classes are cancelled due to weather or if the district has a scheduled holiday. In such
cases, students will adjust their start and end dates accordingly to ensure a full 5 days
at each level.
(3) Lastly, please make one copy of this completed form and retain the copy for your records.
PLEASE BRING THIS ORIGINAL, COMPLETED FORM WITH YOU TO YOUR
MEETING WITH LINDA FOSTER, FIELD PLACEMENT COORDINATOR,
WHICH MUST TAKE PLACE BY WEDNESDAY, SEPTEMBER 24, 2014. You
will also need to bring with you three (3) copies of your resume.
.
PLEASE COMPLETE ATTACHED DATA SHEET
Field Experience and School Partnerships Office
Education Building – Room 1105
(607) 753-2824
(607) 753-5966 (fax)
Teacher Candidate Data Sheet
WINTER/SUMMER BREAK FIELD PLACEMENTS
Please Print Neatly:
Male ❐ Female ❐
Name ________________________________________________ C#______________________________
(Last)
(First)
E-Mail Address
Local/Campus Address ________________________________________Local Phone ____________________________
Home Address ______________________________________________Home Phone____________________________
Emergency Contact Info (Name & Phone # of Parent/Spouse, Etc.)_______________________________________________
 Yes
 Yes
 Yes
 No
 No
x No
Are you a CURE student?
Are you an International Student with an F or J visa? (If yes, please circle F or J)
Do you currently hold NYS teaching certification? (If applicable)
F or J
Fingerprinting: “A teacher candidate who receives an early field experience placement in a school district that requires fingerprinting
will be expected to complete a fingerprinting application one week prior to beginning their student teaching placement (if they have not
previously done so). Digital fingerprinting is now available at the Office of Career Services; contact Career Services at (607) 753-4715 to
set up a fingerprinting appointment to complete the application.”
Failure of adherence to this requirement will result in cancellation of your placement.
CRN# (Ex: 94841) ____ 90730__________
Section# (Ex: EDU 392-601) ________EDU 256______
Course Instructor __Dr. Bailey___________________________________________
Early Childhood Ed. (Birth - 2)
Early Childhood/Childhood Ed. (Birth – 6)
XXX Physical Education
# of Hours
Required __60___
Semester: Fall
 Physics 
AED Science
Chemistry
Biology 
Health Education
Earth Science 
Childhood Ed. (1 - 6)
Master of Science in Teaching (MST) (1 - 6)
Inclusive Special Education
AED English 
AED ICC
ESL French  Spanish 
AED Mathematics
Physics/Math 
What geographic area are you contemplating for student teaching?_______________________________________________
ADDITIONAL INFORMATION/SPECIAL CONCERNS: (Please be specific.)
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Please note: The Field Placement Office will be unable to make a placement for you if all requested information is not
provided.
DOCUMENTED DISABILITY: SUNY Cortland is committed to upholding and maintaining all aspects of the federal Americans with Disabilities Act of 1990 (ADA)
and Section 504 of the Rehabilitation Act of 1973. If you are a student with a disability and wish to request accommodations, please contact the Office of Disability
Services located in B-1 Van Hoesen Hall or call 607-753-2066 for an appointment. Any information regarding your disability will remain confidential and will
only be divulged with your written permission. Because many accommodations require early planning, requests for accommodations should be made as early as
possible. Any requests for accommodations will be reviewed in a timely manner to determine their appropriateness to this setting.
STUDENTS MAY NOT ARRANGE THEIR OWN PLACEMENTS.
I hereby attest to the completeness, truth and accuracy of all the information which I have provided.
_______________________________________________Signature and Date_______________________________
STUDENT NAME_______________________
C#______________________________
I.
FIRST PREFERENCE FOR A HOST PUBLIC SCHOOL DISTRICT
(Middle/Jr. High and High School Grade Levels)
A. Name of school district (not school building) _____________________________
B. Name of Administrative Contact for the host district with the contact’s title:
(1) Name of Administrative Contact_______________________________
(2) Title of Administrative Contact________________________________
C. MAILING ADDRESS (including zip code), E-mail, telephone number and fax
number for the administrative contact
1. Mailing Address for the Administrative Contact
____________________________________________________________
2. Office Telephone Number for the Administrative Contact:
(_____)_____
3. Fax Number for the Administrative Contact (_____)_____________
4. E-mail address for Administrative Contact_____________________
III.
ALTERNATE PREFERENCE FOR A HOST PUBLIC SCHOOL DISTRICT(Middle/Jr.
High and High School Grade Levels)
A. Name of school district (not school building) _____________________________
B. Name of Administrative Contact for the host district with the contact’s title:
(1) Name of Administrative Contact_______________________________
(2) Title of Administrative Contact________________________________
C. MAILING ADDRESS (including zip code), E-mail, telephone number and fax
number for the administrative contact
1. Mailing Address for the Administrative Contact
____________________________________________________________
2. Office Telephone Number for the Administrative Contact:
(_____)_____
3. Fax Number for the Administrative Contact (_____)_____________
4. E-mail address for Administrative Contact_____________________
Updated 8/22/14 laf