BSC Practicum APPLICATION Fall 2008
Special Education: Teacher of Students with Moderate Disabilities
DUE DATE: February 29, 2008
1. Personal Information:
If necessary, I give permission to release my phone number to my practicum site administrator: yes ___ or no ___
Name:
Banner ID or last 5 SS #:
Street:
Phone:
City:
Cell Phone:
Zip Code:
Email:
2. Practicum Qualifications:
Date admitted to the program: __________
License Level (circle one): Pre K-8 or 5 - 12
Your Program and Course # (circle one)
 Undergraduate
PreK-8 – SPED431
5-12 - SPED432
 Post Baccalaureate/Graduate
PreK-8 -- SPED594
5-12 - SPED595
 Dual License
SPED404 – INCLUS.
SPED594 – SUB. SEP.
3. Completed Coursework:
UNDERGRADUATE
Current GPA: ________
Indicate the dates (month/year) for passing these
MTELs:
General Curriculum or Subject: _________
(required before the practicum)
Foundations of Reading:
(required for licensure)
or
_________
GRADUATE
Sem./Year
Sem./Year
________ SPED202/211
________ SPED202/211/510
________ SPED203 Diversity
________ SPED508 Diversity
________ SPED302 Behavioral Management
________ SPED575 Behavioral Management
________ SPED303 Assessment
________ SPED530 Assessment
________ SPED402 Reading
________ SPED402/520 Reading
________ SPED403 Curriculum
________ SPED504/SPED505 Curriculum
________ PSYC224/PSYC227 Developmental Psychology
________ PSYC224/PSYC227 Developmental Psychology
Circle courses are you requesting course substitutions. Have you submitted the necessary documents?
PSYC 224/227 Yes No SPED 202/510 Yes No
SPED 402 Yes No SPED 508 Yes No
Practicum Yes No
4. Documentation of Prepracticum Experience in a Diverse Setting:
Location (school or collaborative, town): ____________________________________________________________
Course during which this experience occurred: _______________________________________________________
Ethnic diversity of the students: __________________________________________________________________
Practicum (Student Teaching)
5. Assigned by Field Placement Office (Undergraduate, Graduate):
Where will you be living?______________________________________________________
Site(s) preferences (# 3 choices):
_______ Brockton
______ Randolph
_____ Avon
______ Plymouth
______ New Bedford
_____ Barnstable
______ Quincy
______ Norwood
_____ Bridgewater/Raynham
______ Stoughton
_______Other (requires approval)
Inclusion (Indicate your preference):
Substantially Separate (Indicate your
preference):
PreK – 8: Pre K – 4 _____ or 5 – 8 ______
PreK – 8: Pre K – 4 _____
5 – 12:
5 – 8 _____
or 9 – 12 _____
5 – 12:
5 – 8 _____
or 5 – 8 ______
or 9 – 12 _____
6. Employment Based (Graduate)
If you are currently employed, complete the attached Employment Based Practicum Signature Sheet and return to
the Special Education Department with required signatures.
 Check here if you are seeking an employment based practicum (Graduate)
Inclusion:
Substantially Separate:
________I am requesting to use my employment as an
Employment Based Practicum.
________I am requesting to use my employment as an
Employment Based Practicum.
OR
OR
________I am requesting a waiver for this experience
________I am requesting a waiver for this experience
7. Signatures: Please read and only sign if you understand all requirements:
I understand the following: the practicum is a full semester, full-time, 5-day per week experience, the Office of Field Experience
will use the above information to select a practicum site for me, and I should not contact a school regarding potential placement
or my grade level preference. Once this form is submitted to the Office of Field Experience and Licensure, a request to change
a placement may result in delaying my practicum to the following semester. Once I am notified of a placement I will complete
my practicum experience at the site and in the grade level assigned. I have met all requirements for admission to student
teaching (see attached instructions) including passing scores on all appropriate portions of MTEL. Finally, a Criminal
Offender Record Information (CORI) request is processed by the practicum site, and an unsatisfactory CORI report is a reason
for refusal of placement by the Office of Field Experience and School District.
Student Signature:
Date:
_______________________________________________________
__________________
(Department signature indicates student has met all program requirements for student teaching eligibility)
Grad. Coordinator (for
graduate students) or
Dept. Chair (for
undergraduates)
Signature:
________________________________
Graduate Coordinator
__________________________________
Department Chair Person
Student Approved for
(Indicate Course # and/or
substitution):
Date:_____________
Inclusion
Substantially Separate
Date:_____________
Special Education
Employment Based Practicum Signatures
Required for all Candidates seeking an employment based practicum
All parts of this document are necessary and due with the application. All employment based
practica must meet the Massachusetts Department of Education Requirements, and approval is
subject to review by the Department of Special Education and Communication Disorders.
Name:
Date:
School where you work:
Town/District:
Principal:
School Address:
Phone:
Program type (Substantially separate, Inclusion):
Grade Level(s):
Ages:
Required Signatures (signatures confirms employment and approval to undertake an employment
based practicum):
Immediate Supervisor:
Director of Special Education:
BSC Department Chair:
Supervising Practitioner -- Indicate the name of your prospective Supervising
Practitioner:
Work Description: Attach documentation that describes your employment as a special
education teacher. This can often be obtained from your district’s or school’s human
resources office.
Your Signature:
Directions for Completing the BSC Special Education Practicum
Application for Fall 2008
Due Date: February 29, 2008
Due to the large number of applications that we are now receiving, strict adherence to the due date is
mandatory to ensure timely completion of assignments to schools, documenting the completion of
licensure requirements, and the assignment of program supervisors.
Please note that incomplete applications will not be accepted. When you submit your application, you
must be present at BSC, and you must give your application to one of the following in the Department of
Special Education and Communication Disorders (DSECD):
Mary Comeau, Administrative Assistant
Hilary Loranger, Graduate Assistant
Ken Dobush, Practicum Coordinator
To be complete,
1. All appropriate sections must be filled in
2. All documentation for Course/Field Experience Waivers
(http://www.bridgew.edu/LicensureFieldPlacement/ ) must be signed by your advisor and included with the
application
3. If requesting an employment based practicum, the signature page must be complete and a work
description included on a separate page.
Specific directions for each section:
1. Personal information
Name: If you have changed your name after being accepted into your program, enter the name that is your
current BSC name used for registration purposes.
Address: Indicate the most current address where you wish to have all program information sent.
Phone number: Use a phone number we can use to contact you during your practicum experience.
Email: Use an email address we can use to contact you during your practicum.
Please note that the DSECD routinely uses Blackboard VC 150 (undergraduates) and VC 151 (graduates)
to communicate by email.
2. Practicum Qualifications:
If your GPA drops below 2.8 at the end of the current semester, you will not be eligible to student teach
until the GPA is brought back up to at least 2.8.
Subject score from the May 10, 2008 test date is the last eligible score for practicum. If you do not have
a passing subject score by June 13, 2008, you will not be eligible for a practicum.
Be sure to complete all parts of this section.
3. Completed Coursework:
All coursework listed must be completed before the practicum. Any exceptions must be approved by the
Practicum Coordinator.
For courses taken at another institution, a Course/Field Experience Waiver
(http://www.bridgew.edu/LicensureFieldPlacement/ ) must be provided at the time your application is
submitted.
4. Documentation of Pre-practicum Experience at a Diverse Setting:
All students are required to have a portion of their field experience take place in a classroom with a
ethnically diverse student population (African American, Hispanic, etc.) This requirement can be fulfilled
during the 40-hour field experience required in your introductory course or in the required experiences of
the other professional education courses. If you have satisfied this requirement, indicate the location,
course, and ethnic diversity of the students. Otherwise, this requirement must be met in your practicum.
5. Practicum (Student Teaching):
Assigned by the Licensure and Field Placement Office (undergraduate and graduate):
Assigned placements are made to schools that are within 45 minutes driving time of the community in
which you live during the practicum. The college does not provide transportation to any schools.
Students are not to contact school districts to make their own placements. All request must go through the
Licensure and Field Experience Office (508-531-1227).
After your application has been accepted, if you need to cancel your practicum for any reason, call the
Field Experience Coordinator at 508-531-1227.
6. Employment Based Practicum (graduate):
If you are currently seeking employment, check this box. This allows us to plan your placement to best
meet your needs whether or not you find a teaching position.
If you are currently or know you will be employed as a special education teacher, the Employment Based
Practicum Signature document must be completed and turned in with the application. A work description
is also required on a separate page. You may be able to get this from your school districts human
resources office. It may also be the responsibilities section of the job openings description.
If you do not find employment please contact the Field Placement Coordinator at 508-531-1227.