Childhood Education and Family Studies
2015 Field Experience and Practicum FORMS
1988 Newmark Avenue, Coos Bay, OR 97420
(800) 962-2838 (541) 888-7290
(541)888-7953 fax
www.socc.edu
Email us at ece@socc.edu
Visit our Website at:
http://www.socc.edu/dept/childed-famstudy/index.html
SWOCC Field Experience and Practicum Forms 2015
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Field Experience - Welcome Letter
Childhood Education and Family Studies Program
Greetings Potential Practicum Student!
Southwestern Oregon Community College (SOCC) Childhood Education & Family Studies (CE&FS)
certificate and degree programs each require the successful completion of practicum courses to ensure
that students have the skills required to be effective and professional early childhood practitioners in the
field.
All practicum students must be listed on the Criminal History Registry as required by your state's
certification regulations, attend a weekly seminar (online or face-to-face), participate in reading,
assignments, and journaling, observe and assess children, develop a portfolio on one child in the
classroom over the term, develop lesson plans to be implemented in the classroom and work directly with
children to complete each practicum course. Out of district students are required to submit video tapes of
their work in the classroom at weeks 3, 6, and 9 of the term.
Practicum students must complete sixty-six (66) hours in an approved classroom site during the term. In
district (local - Coos Bay) students complete these requirements at the on campus facility – The Family
Center. Out of district students must complete the practicum requirements for their CE&FS program in an
approved site that will allow them the opportunity to complete all of the practicum hours and
presentations. For the approved worksite, we prefer NAEYC Accredited, Military Programs, or Head Start
Programs, as their quality standards are higher than the State of Oregon’s. We will try to work it out on an
individual basis for areas that do not offer these types of programs. At this work site, you will work as a
member (volunteer or paid) of the teaching team to complete the required practicum elements.
You will need to find a qualified supervising teacher at the approved worksite if you live out-of-district. The
Family Center has qualified supervisors working at the site. The qualification form can be found below this
letter. Your supervising teacher completes evaluation forms of your skills and work at the middle and end
of the ten week term. Students must receive an 85% or higher on these evaluations in order to pass the
practicum courses. In addition to these evaluations, there will be self-evaluations and instructor
evaluations.
Please feel free to contact me if you have any questions or concerns.
Dr. Rosengarden
Childhood Education and Family Studies Faculty
Office Phone: 541-888-1575 Family Center Building Office #108
Southwestern Oregon Community College
1988 Newmark Avenue
Coos Bay, Oregon 97420
FAX 541-888-7953
SWOCC Field Experience and Practicum Forms 2015
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Field Experience
Application for Placement Form
Childhood Education and Family Studies Program
Participant’s Name: __________________________________________________________________
Telephone: (____) _____________
Email Address: ______________________
If completing your field experience hours at Educare on the Coos Bay campus of SWOCC, you
will not have to complete the rest of this form – simply indicate you will be using Educare below:
I will be using the Educare Facility as my site (circle): YES NO
Field Experience Mentor Teacher: Dan Birskovich
SWOCC Coos Bay Campus, Family Center Email: dbirskovich@socc.edu Phone: 541-888-7445
Signature of Participant
Date
If you are not completing your hours at Educare in Coos Bay, you must:
1. Obtain permission from your Field Experience Course Instructor by completing and
submitting this completed form.
2. Submit the Mentor Teacher Letter (completed by the mentor teacher) to your instructor.
3. Submit the Field Experience Application for Placement Form (completed by both the
participant and the mentor teacher).
Site Information for Field Placement
Name of Site: __________________________________________________________________
Name of Potential Mentor Teacher at Site: _____________________________________
Address of Site: __________________________________________________________________
Telephone: (____) _____________
Email Address: ___________________________________
Signed ________________________________________
Participant
SWOCC Field Experience and Practicum Forms 2015
Date: ____________________________
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Emergency Information Form
Childhood Education and Family Studies Program
Participant’s Name: __________________________________________________________________
Home Address: ______________________________________________________________________
Telephone: (____) _____________
Age: _______
Birthdate: _____/_____/______
EMERGENCY CONTACT(S)
1. Name:________________________________________________________________________
Address: ______________________________________________________________________
Relationship:______________ Home Phone (_____)_______Work Phone (_____)___________
2. Name:_______________________________________________________________________
Address: _____________________________________________________________________
Relationship: ____________ Home Phone (_____)_________Work Phone (_____)___________
Personal Physician’s Name: ____________________________________________________________
Address______________________________________________________ Phone(_____)__________
Medical Information
I am taking the following medication ____________________________________________________
I am allergic to: _____________________________________________________________________
Prescription Eyewear
Y ____
N ____
Please state any medical conditions of which emergency staff needs to be aware:
Signed ________________________________________
Participant
Date:____________________________
(If under 18 years of age)
Signed _________________________________________ Date: ___________________________
Parent/Guardian (If participant under 18 years of age)
SWOCC Field Experience and Practicum Forms 2015
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Statement of Agreement for the Filed Experience Manual
Childhood Education and Family Studies Program
I, ______________________________________________________________, hereby certify
that:
1. I have read and will demonstrate ethical practices as identified in the NAEYC Code of
Ethical Conduct.
2. At the start of this quarter I updated my personal information with SWOCC. This
information includes e-mail, phone, immunization records, and emergency contacts.
3. I have a current criminal background check, or, will submit my background check prior to
the start of my field experience placement.
4. I have received and read all of the field experience expectations outlined in the current
field experience manual. I have asked questions and received satisfactory explanations
about any expectations that were unclear. I agree to abide by all
expectations/requirements/etc. outlined in this document.
_______________________________________
______________
Signed
Date
SWOCC Field Experience and Practicum Forms 2015
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Field Experience
Mentor Teacher Instructions
Childhood Education and Family Studies Program
Dear Colleague,
Thank you for taking the opportunity to consider placement as a mentor teacher and placement
site for one of our Childhood Education & Family Studies field experience teacher candidates.
Southwestern Oregon Community College (SWOCC) Childhood Education & Family Studies
(CE&FS) certificate and degree programs require the successful completion of field experience
(practicum) courses to ensure that teacher candidates have the skills required to be effective and
professional early childhood practitioners in the field.
All distance field experience teacher candidates must be listed on the Criminal History Registry
as required by your state's certification regulations, attend an online seminar, participate in
reading and journaling, assess children based on anecdotal recordings, and work directly with
children to complete each field experience course.
Field experience may also include developing a portfolio on one child in the classroom over the
term, and developing lesson plans to be implemented in the classroom. Teacher Candidates
must complete 66 hours in your classroom during the term. Assessment is completed by you,
the mentor teacher, halfway through the placement and at the end of the placement.
Additionally, the course instructor evaluates the teacher candidate by either visiting the
placement site or having the teacher candidate submit audiovisual recordings of his or her
participation in the classroom.
In district (Coos Bay) teacher candidates complete these requirements at our on-campus
Educare facility. Out of district teacher candidates must complete the field experience
requirements for their CE&FS program in an approved site that will allow them the opportunity to
complete all of the field experience hours, audiovisual recordings, and presentations.
As a Mentor Teacher you agree to provide a placement site where the teacher candidate would
be able to work as a member of your teaching team to complete the required field experience
elements. You will agree to supervise the student (teacher candidate) while he or she is
completing field experience classroom participation requirements.
Student assignments during the field experience will include anecdotal recordings of the children
in your classroom. The teacher candidate should be viewed as an asset to your class and as an
additional adult focused on the needs of the children
As a Mentor Teacher you also agree to complete an evaluation form of the teacher candidate at
the middle and near the end of the eleven-week term. Students must receive an 85% or higher
on these evaluations in order to pass the field experience courses. Your feedback is important
to us as we strive to promote only competent, knowledgeable teacher candidates who have the
SWOCC Field Experience and Practicum Forms 2015
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ability to apply what they have learned. With your continued help, our degrees in early care and
education will continue to stand for excellence in the field.
Some teacher candidates may require more time to develop skills that support them in becoming
more capable and prepared for the next step in their educational journey. We encourage you to
communicate any concerns you might have with us and in your evaluations.
Please feel free to contact us if you have any questions or concerns. Your participation is a
necessary and valuable support to teacher candidates who are pursuing their education to
become the future educators of our children. Thank you for your consideration and willingness to
help shape future teachers of young children.
SWOCC Field Experience Instructors,
Laurie Potts – Director, Family Center, Email: lpotts@socc.edu
Dan Birskovitch – Supervising Teacher, Email: dbirskovich@socc.edu
Giovanna Hite – Adjunct Faculty, Email: Giovanna.hite@socc.edu
Maidie Rosengarden – Assistant Professor, Email: Maidie.rosengarden@socc.edu
(THIS SECTION IS TO BE FILLED OUT BY THE MENTOR TEACHER, and submitted by the
Field Experience Student).
_____I am interested and willing to be a Mentor Teacher for a teacher candidate form SWOCC’s
Childhood Education and Family Studies Program.
Name: ________________________________ Title: _________________________________
Worksite Qualifications: ________________________________________________________
Number of years’ site has been in operation: ___________
Please describe type of site below listing how the site is accredited and/or licensed. Please
attach a brochure/statement of philosophy/or any other materials that provide information about
your site.
SWOCC Field Experience and Practicum Forms 2015
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Field Experience
Application for Placement Form – Mentor Teacher
Childhood Education and Family Studies Program
I ____________________ (name of Mentor Teacher) meet the eligibility requirements as follows
(Please check each area):
PERSONAL
 Affirm ability to relate to people of various racial, ethnic, and socioeconomic backgrounds.
 Knowledgeable about local, state, and national requirements, standards, and guidelines for child
care programs serving children age birth through 5 years.
 Familiar with the center where the Teacher Candidate will be observed, and the needs of families
and children in the community.
___ Yes, I meet this requirement.
CONFLICT OF INTEREST
To promote objectivity and credibility, an individual serving as a Mentor Teacher may:
 Not be working as co-teacher with the Teacher Candidate on a daily basis in the same room or
group.
 Not be the relative of a child in the Candidate's care at any time during the assessment process.
 Not be related by blood or marriage or other legal relationship to the Candidate.
___ Yes, I meet this requirement.
EDUCATION AND EXPERIENCE
Mentor Teacher must meet all of the requirements in one of the three combinations of education and
experience outlined in options 1, 2, or 3 below:
Option 1:
B.A., B.S., or advanced degree in early childhood education/child development, home economics/child
development, from an accredited college or university. Must include 12 semester hours covering children
ages birth through 5 years.
Two years of experience in a child care setting serving ages birth through 5 years, including:
1 year working directly with children in the same age range as the children in Candidate's classroom as a
caregiver, teacher, child life worker, social worker, or similar role; and 1 year of responsibility for the
professional growth of another adult.
Option 2:
Associate level (two-year) degree in early childhood education/child development, home economics/child
development, from an accredited college or university. Must include 12 semester hours covering children
ages birth through 5 years.
SWOCC Field Experience and Practicum Forms 2015
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Four years of experience in a child care setting in a program serving children ages birth through 5 years,
including 2 years working directly with children in the same age range as the children in Candidate's
classroom as a caregiver, teacher, child life worker, social worker, or similar role; and 2 years of
responsibility for the professional growth of another adult.
Option 3:
An active CDA Credential plus twelve semester hours of study in early childhood education or child
development at an accredited college or university covering children ages birth through 5 years.
Six years of experience in a child care setting serving children ages birth through 5 years, including 4
years working directly with children in the same age range as the children in Candidate's classroom as a
caregiver, teacher, child life worker, social worker, or similar role; and 2 years of responsibility for the
professional growth of another adult.
Date of CDA __________
___ Yes, I meet this requirement through Option ____
Degree(s) & Institution(s): _____________________________________________________________
Work Site for Experience: _____________________________________________________________
I AGREE:

To allow the Teacher Candidate to work in the classroom.

To allow the Teacher Candidate to write and share observations and reflective journals about the
experience (names will be changed to protect privacy).

To allow the Teacher Candidate to create a Portfolio of an individual child in the classroom (with
parent approval).

To allow the Teacher Candidate to videotape group and circle time presentations for review by
the course instructor (&/or allow access for the SWOCC course instructor to observe the teacher
candidate on site if possible).

To supervise the teacher candidate during his or her work in my program.

To complete evaluations of the teacher candidate's work
___ Yes, I agree to this requirement.
Signature of Mentor Teacher
SWOCC Field Experience and Practicum Forms 2015
Date
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Release of Information Form
Childhood Education and Family Studies Program
I,
give permission for:
(Teacher candidate)
(Course instructor) and (Mentor teacher):
to exchange pertinent information concerning the field experience placement and myself.
This consent is to expire on: (1 year from date of signature): ___________________________
SIGNED:
Teacher Candidate
(date)
Mentor Teacher
(date)
Course Instructor
(date)
SWOCC Field Experience and Practicum Forms 2015
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Statement of Confidentiality for Employees
Childhood Education and Family Studies Program
The Southwestern Community Partnership Family Center
1988 Newmark, Coos Bay, Oregon 97420, 541-888-7290, FAX 541-888-7953
Confidentiality Statement
Contact between the child, child parent(s)/guardian(s), or any child record or information pertaining to
children and families in the Southwestern Community Partnership Family Center is highly privileged and
confidential. Therefore, it is your responsibility to hold in absolute confidence all information regarding any
Southwestern Community Partnership Family Center child and family. This means that no information can
be given out concerning any Family Center child and/or family to anyone outside the center. “Anyone”
includes your spouse, children, friends, and relatives. If any child services agency requests information
from you, refer them to your supervisor.
Because confidentiality rules involve not only decency and common courtesy, but legal liability as well, any
employee or volunteer who breaks the rules of confidentiality in any manner will lose their Family Center
position immediately.
Standard of Quality Care Statement
As an employee, or volunteer, of the Southwestern Community Partnership Family Center, the safety, care
and well-being of children must be our first priority. Young children in our care do not yet have the
developmental capability of acting in their own best interests. It is our explicit responsibility to attend to the
safety provisions for all children as a standard of quality care and best practices. Any act, conduct, or lack
of attention and support that places a child at risk, or causes injury to a child, will be just cause to lose your
position immediately.
Professional Responsibility and Ethics
As a worker in the Family Center you are expected to treat and communicate with both staff and families
with the highest level of respect and courtesy. You are expected to follow the center’s “Problem Solving
Plan”. If you
have a question or concern regarding a policy or personnel in the center, first address the
concern with the individual or your supervisor and then work cooperatively towards a solution. If the
concern remains unresolved, address the manner with the center coordinator.
I have read and understand the rules of confidentiality, the responsibilities included in maintaining
the standard of quality care for all children in my position, and the expectations regarding
professional conduct. I agree to this and understand these policies.
My photograph may be used for class displays, yearbooks, and program marketing. Yes
Student/Employee Name (Print)
Student/Employee Signature
No
Date
Site Supervising Teacher’s Signature
SWOCC Field Experience and Practicum Forms 2015
Date
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Statement of Confidentiality
Childhood Education and Family Studies Program
Contact between the student and the employer is highly privileged and confidential.
Therefore, it is your responsibility to hold in confidence any and all information regarding
the school, school employees, and its clients (children and families). This means that
no proprietary information can be given out concerning the school or clients to
ANYONE outside the agency where you are working as a student. Anyone includes
your spouse, children, friends, and relatives.
Because confidentiality rules involve not only decency and common courtesy, but legal
liability as well, a student/employee who does not meet the confidentiality expectations of
the employer may lose the field experience opportunity. If a student loses the placement
due to violation of confidentiality, no credit will be issued for that term of field placement.
This could affect your ability to graduate from your Southwestern program.
I have read and understand the rules of confidentiality and agree to this policy.
Student Name (Print)
Date
______________________________________________________________________
Student Signature
Site Supervising Teacher’s Signature
Date
SWOCC Field Experience and Practicum Forms 2015
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SWOCC Field Experience – Child Portfolio Parent Permission Form
Teacher Candidate’s Name ___________________________________________________
I (Parent's name, printed) _____________________________________, give permission for the
teacher candidate named above to collect observation notes, photos, work samples, etc. from
my child during this quarter (
). I understand that the teacher candidate will put the
samples into a portfolio and I agree to meet with the candidate during the last week of class to
allow him/her to present and explain the portfolio to me. I understand that after the presentation,
the teacher candidate must turn the portfolio in to the instructor at Southwestern Oregon
Community College. (Parents - If you put YOUR mailing address with the portfolio, the course
instructor will return the portfolio directly to you after it is graded.)
Thank you for helping our teacher candidate in their learning process!
Signature of Parent ________________________________________ Date ________
Every effort will be made to respect confidentiality. Children will not be named in
materials used outside of their own portfolios.
Child’sName______________________________________________________
Parent/Guardian’s Name: ____________________________________________
Parent/Guardian’s Signature: __________________________________________
Date: ____________________________________________________________
SWOCC Field Experience and Practicum Forms 2015
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Photography and Video Release Form
I give my permission for my child to be photographed and videotaped in the child care setting:
_____________________ by Southwestern Oregon Community College students and mentor
teachers. I understand that the photographs and videos will be used for educational purposes
including:

Displays in the classroom and hallways.

In my child and other children’s portfolios/assessment materials.

In the student teachers’ professional portfolios.

For training and professional development materials created by Southwestern Oregon
Community College professors for use both within and outside of the college.

Photographs may be used in a collage or photograph given to student teachers at the
end of the quarter to celebrate and remember their hard work. It will not be shared
publically, but may be displayed in their home or future office space.
Every effort will be made to respect confidentiality. Children will not be named in
materials used outside of their own portfolios.
Child’sName______________________________________________________
Parent/Guardian’s Name: ____________________________________________
Parent/Guardian’s Signature: __________________________________________
Date: ____________________________________________________________
SWOCC Field Experience and Practicum Forms 2015
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Field Experience Time Log
Childhood Education and Family Studies Program
Teacher Candidate’s Name _______________________ Month ______________________ Year 20__
Date
Time In
Time Out
Total Hours
SWOCC Field Experience and Practicum Forms 2015
Teacher Candidate Signature
Mentor Teacher
Initials
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