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Local Placement Request Form

Form should be returned to field@liberty.edu. Only students considered LOCAL to the Central Virginia area should complete this form. Please do not submit this form if you are not completing placement in the Central Virginia area. All portions of the form must be completed by the deadline to process the request.

Requests should be submitted by Wednesday of WEEK ONE. Late requests will not be accepted for the current term.

Student Information Today’s Date: Click or tap to enter a date.

Full Name:Click or tap here to enter text. LU Student ID: Click or tap here to enter text.

LU Email ONLY: Click or tap here to enter text. Seeking Licensure: ☐Yes or ☐No

Endorsement Area(s): Choose an item. Local Address: Click or tap here to enter text.

Course Information

Course: Choose an item. Instructor Name: Click or tap here to enter text.

Course # (Undergrad): Choose an item. Instructor Email: Click or tap here to enter text.

Course # (Graduate): Choose an item. Section #: Choose an item.

Term (A/B/D): Choose an item.

Placement Preferences

Hours: Choose an item. Grade Preference: Choose an item.

Classroom Setting: Choose an item. School/Location: Click or tap here to enter text.

School Employment

Employed in the school system: ☐Yes or ☐No Title/Position: Click or tap here to enter text.

School System/Building: Click or tap here to enter text.

Placement Agreements: All statements must be checked for request to be processed.

☐ I understand that my request must be completed and submitted by Wednesday of Week One for my request to be processed.

☐ I understand that if I submit a late request, it will not be accepted for the current term and my placement will be requested in the next sub-term.

☐ I understand any school, private or public, within the following areas is considered LOCAL: Amherst, Appomattox, Bedford, Botetourt, Campbell, Danville, Lynchburg, Nelson, Pittsylvania, Roanoke, and Salem.

☐ I understand that I may be placed in ANY of the local school systems for my practicum. The field office cannot guarantee placements based on preferences or special requests. NOTE: Preferences are NOT guaranteed.

☐ I understand that I am NOT permitted to contact any of the local schools to make my own arrangements, under any circumstances, even if I have a friend or family contact in the school system. All LOCAL placements must be coordinated through the Local Field Office (field@liberty.edu).

☐ I understand that I must complete and receive full clearances for the School of Education background, fingerprinting, and Virginia child abuse before I may begin my placement. I understand I am responsible for the fees associated with this background check.

☐ I understand that I am responsible for completing any additional background check processes required by the assigned school system.

☐ I understand I will receive an email from field@liberty.edu as soon as the school system confirms a placement for me. This may take several weeks for the school system(s) to process.

☐ I understand that I am responsible for providing my own transportation to my assigned local placement.

☐ I understand that my placement will NOT be changed once it is confirmed by the school system.

☐ I understand that I am responsible for contacting the Local Field Office immediately should I no longer need placement or if my placement needs change.

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