CLINICAL EDUCATOR REGISTRATION - Florida Atlantic …



CLINICAL EDUCATOR REGISTRATION – PRACTICUM STUDENT

A Certificate of Participation will be issued to each clinical educator for his/her participation after receiving THREE students enrolled in a Practicum Course for a degree program in the Department of Teaching and Learning. It entitles the recipient to register at any state university in Florida without payment of tuition for ONE semester for up to six semester credit hours. The certificate is NON-TRANSFERABLE. Please secure it in a safe place as lost certificates cannot be replaced.

Clinical Educator Information:

Name ___________________________ Social Security # (Required by state)

Phone #: Professional Email Address ________________________________________

Mailing Address

District ___________________ School Name

School Address

Developing Teacher Information:

Name Semester __ Fall __Spring Year

Name Semester __ Fall __Spring Year

Name Semester __ Fall __Spring Year

1. Complete this form in its entirety. Please wait until all three FAU students have completed the clinical experience prior to submitting the application.

2. Attach photocopies of Final Evaluation form for each student.

Submit this form and students’ final evaluations to:

Please FAX or SCAN to the Office for Clinical Experiences:

Palm Beach, Indian River, Okeechobee, St. Lucie, Martin

Fax: (561) 297-2991 or Email: stuteach@fau.edu

Broward and Miami-Dade Counties

Fax: (954) 236-1022

I certify that I have either attended an orientation meeting for Clinical Educators within the last twelve months or reviewed all materials available on the FAC Clinical Educator Orientation web page at the start of the current semester.

______________________________________ __________________

Clinical Educator’s Signature Date

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