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|[pic] |Intern Placement Assignment/Agreement |

This page is to be completed by college and school district Staff Only:

Duval County Public Schools: Once the agreement is signed by all parties, please return this page to levertl@ or mail to Lynn Levert, Building 3001, Human Resource Services, Intern Placement, Duval County Public Schools, 1701 Prudential Drive, Jacksonville, FL 32207.

Other counties/schools: After all parties have signed the agreement, return to Field Experience, School of Education, Florida State College at Jacksonville, 101 West State Street, Jacksonville, FL 32202, email to Roshella.Waters@fscj.edu , or fax to 357-8926.

|We, the undersigned, agree that |      |be assigned to |

| |Name of Student | |

|intern at the following school during the |      |Spring or |      |Fall term. |

|      | |      |

|Date | |Signature or Electronic Agreement of Field Experience Facilitator |

|      | |      |

|Date | |Signature or Electronic Agreement of County Superintendent or Supervisor |

|      | |      |

|Date | |Signature of Principal |

| | |      | | |

| | |Name of School | | |

| | |      | |

| | |School Phone Number | |

| | |      |

| | |School Address (Street, City, Zip Code) |

| | |      | |      |

| | |Type or Print Name of Directing Teacher | |Grade/Subject |

| | |      |

| | |Directing Teacher E-mail Address |

| | |3+ years successful teaching Yes No |

| | | |

| | |CET Trained |

| | |Area(s) of Certification |

|      | |      |

|Date | |Signature or Electronic Agreement of Directing Teacher |

Intern Information

|      |      |      |

|(Name) Last First Maiden |

|      | |      |

|(Address) Street Apt. # City, State, and Zip code |

|      |      |      |

|Primary Phone Number |Alternate Phone Number |Student E-mail |

|      |      |      |

|Sex |Race |Date of Birth |

Florida Teacher Certification Exams

For each exam passed, provide the Pass Date or enter NONE. If you have not taken the PK3 Subject Area Exam or the Professional Education Exam, provide a scheduled date or Projected Scheduled Date. All Florida Teacher Certification Exams must be passed in order to graduate from the BS ECE program with the state of Florida.

The General Knowledge (GK) exam must be passed prior to your Internship. ____ Initial Here

|Test |Pass Date |Scheduled Date |Projected Scheduled Date |

| General Knowledge | | |

|Math |      |      |      |

|English |      |      |      |

|Reading |      |      |      |

|Essay |      |      |      |

| PK3 Subject Area Exam (SAE) |      |      |      |

| Professional Education Exam (PEd) |      |      |      |

|      |

|Student Name |

Initial Understanding Portfolio

The Initial Understanding Portfolio is considered an entrance requirement for the internship. You are expected to submit all sections of the portfolio before the internship begins.

District Preference and Fingerprinting Status

*Fingerprint results do not transfer from district to district or from agency (i.e. VPK) to school district. Please contact the field experience staff if you have questions about the process.*

Choose only one district and fingerprinting status below. I would like to intern in the following county:

| |Clay |

|      |I DO NOT require fingerprinting because I am a substitute or employee of the school district chosen |

|      |I DO NOT require fingerprinting because I was PREVIOUSLY FINGERPRINTED by the school district chosen |

I understand that I will need to be fingerprinted within one month of submitting the internship application. I will contact the Field Experience Office for fingerprinting information if I have any questions. _____ Initial Here

Placement Preferences

Note: The college, district, and school will determine the most appropriate placement for each student.

All placement decisions are final. Students should NOT call a district office concerning placement. Students will be notified of their placement at the orientation meeting held annually at the end of November or May.

|      |

|Student Name |

Special Accommodations

If you have a disability, which will require accommodations during the internship, please describe the type of disability and specify the accommodations you will require (e.g. interpreting, physical limitations, etc.)

| |

|      |

Special Request

If you are a current school employee, substitute teacher or a volunteer requesting a particular school, have the Principal or Vice Principal write a short letter requesting your intern at his/her school. The letter must be submitted with your application, not at a later date. This does not guarantee that you will be placed at the requested school; it simply confirms a specific request.

Essay

Please complete an essay on the topic noted below. This essay will be read by school district officials, principals, and teachers. If an essay is inadequate it may hurt your opportunity to intern at a specific school. Your essay should be specific, concise, and include research to support your statements about teaching. Write about specific skills you possess.

Essay Topic: Why do I want to be a Teacher?

Type Essay Below (space will be added as you type). Please single space and double space in between paragraphs:

|      |

|Student Name |

Acknowledgement

I have read and understand the conditions of Internship and agree that I will fulfill the obligations of this agreement.

I understand that there can be no guarantee of placement as requested, that all internship placement decisions are final, and agree to accept the placement assigned. I agree to abide by all policies, rules and regulations of Florida State College at Jacksonville, the cooperating school, and district in which I am placed. I understand if I am dismissed from my placement, I will be required to complete remediation by Florida State College at Jacksonville.

I understand if I am dismissed from my placement, I must complete remediation prior to being allowed to reenroll in the internship in a later semester. I agree that I have one opportunity to successfully complete the internship after remediation. If I am unable to complete the second internship, I understand that I will be dismissed from the Bachelors in Early Childhood Education program at Florida State College at Jacksonville. I hereby give my consent for the Office of Educational Field Experiences to release all information contained in this application to the county, to the principal of the school(s) to which I am assigned, to my directing teacher, and to my college supervisor.

If, for any reason, I am unable to fulfill my internship commitment, I will notify the School of Education immediately in writing.

|      | |      |

|Signature | |Date |

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