Student Request for Field Placement


(*) denotes required information.

* First Name:
* Last Name:
* Email:
* Date of Application ex. xx/xx/xxxx
* Phone:


* Please make a selection:

Fall Traditional Spring Traditional Weekender Fall Weekender Spring Weekender Summer



* Degree toward which you are working: (choose one)

Early Childhood Education
Early Childhood Education (Pre K-4)
Early Childhood Education (Pre K-4) Special Education (Pre K-8)
Accelerated Early Child hood Education (Pre K 4)
Accelerated Early Childhood Education (Pre K-4)/Special Education (Pre k 8)
Middle Level Language Arts Education (Grades 4-8)
Middle Level Social Studies Education (Grades 4-8)
Teaching: Art Education (Grades K-12)
Teaching: Social Studies (Grades 7-12)/Special Education (Grades 7-12)
Teaching: Child and Society
Teaching: Mathematics (Grades 7-12)
Teaching: Social Studies (Grades 7-12)
Early Childhood Education
Elementary Education
Art Education
Math Education



* Check appropriate course(s) for which you are seeking field experiences:

ECE 1110 ECE 2110 ECE 2115 ECE 3120 ECE 3125 ECE 3130 ECE 3135 ECE 3145

EDUC 1110 EDUC 2125 EDUC 3165 EDUC 3180 EDUC 3195 EDUC 3200 EDUC 3205

EDUC 3210 EDUC 3215 EDUC 3225 EDUC 4115 SPED 2110 SPED 2115 SPED 2120

SPED 3110 SPED 3115 SPED 3120 SPED 3125 SPED 3130 SPED 3135 SPED 3140

SPED 4110 PSYC 2190 EDUC 2205 PSYC 3165 EDUC 3110

EDUC 3140 EDUC 3155 EDUC 2130



Please indicate when you received your clearances. They must be current for the designated school year.
* Date Criminal History Clearance was received: ex. xx/xx/xxxx
* Date Child Abuse Clearance was received: ex. xx/xx/xxxx
* Date Health Appraisal/TB Test was received: ex. xx/xx/xxxx
* Date FBI clearance was received: ex. xx/xx/xxxx

Field Experience

* PDE Stages of Field Work

Field Experience I - Observation
Field Experience II - Initial Experience
Field Experience III - Pre-Student Teaching
Field Experience IV - Student Teaching


Times Available

Indicate the times you are available for observation/participation.

Example: 8am-3pm. Put N/A if not available at all during that day.)

* Monday
* Tuesday
* Wednesday
* Thursday
* Friday

School Information

If appropriate we will honor this request. Please indicate a school building and the district(s) with which you are familiar that might fulfill this requirement. Provide the name of a teacher who may be willing to accept a placement. However, to ensure that students experience a wide range of observation assignments, placement in a variety of school settings is suggested and will be arranged.

Name of Teacher:

Keystone College reserves the right to place students in a setting best suited for observation experiences that are developmental in nature. If at all possible, placement in a school district closest to home or employment will be made.

Students are responsible for their own transportation.