Placement Request for Student Teaching

Candidate's Information:

Email Address:  

  Select your ethnicity American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White  

Requesting Placement Semester:

Have you attended a Georgia high school in the past ten years?:

If so, list the high school you attended: 

High School Graduation Year:

Grade Level(s) Preferred:

Field Placement Area:

MGE Second Concentration:
(MGE Students only)

Select a School System you would like for your student teaching placement:

Placement Site Information:

Due to the heavy volume of placements and the limited number of placements, commutes may be up to an hour (or more) one way, depending on the nature of the placement and the availability of placements in each content area/experience. Should you have a change of address, you are responsible for completing the change of address form located under STUDENTS on CEPP’s site—this form is used for field placements only and does not change your address in Banner. Failure to complete this form should your address change may result in no placement change. Requests placed more than 60 days after the placement request due date may not be honored.

Program Coordinators may elect to identify a cluster of schools to use for field experiences. When this happens, you may be placed in those schools.

All placements are final.

Keeping in mind the above information, please identify four schools in the selected system where you would like to student teach:

Verification of Liability Insurance:
(SPAGE or GAE required)

  Name of Insurance Company SPAGE GAE

Special Accommodations:
(Please see Student Support Services in catalog for disabled student support services)

KSU Policy states you cannot be place in a school with children or relatives. List all the public schools where your children/relatives currently work or attend:

Emergency Contact Information:

Release of Information

I understand that a copy of this placement request, my transcript, the Personal Statement, and the Criminal History Consent Form will be forwarded to the school system in which I am seeking placement for student teaching or to any school system in which the Kennesaw State University Center for Education Placements & Partnerships seeks to secure a placement for me.

I understand that the school system in which I am placed will conduct a Criminal Background Check on me and that I may be required to supply documentation as requested or to submit to fingerprinting at my own expense. (See note on Bartow County below.)

I understand that I am not guaranteed a placement in the schools listed on this placement request nor am I guaranteed the stated grade preference. I certify that the information given on this form is correct to the best of my knowledge and that I have cleared my grade level preference with my program coordinator. I also understand that any school or system may refuse to place me for student teaching for any reason.

School systems may at times request names and email addresses  of teacher education candidates so  that they can contact them about job openings, career fairs, workshops, etc. I agree to release my name and email address to schools for such requests.

I have read and agree to the Release of Information                                              Yes No

Your information is held in confidence

• Please reread your request for completeness and accuracy.
   

• You may submit this request only once.  If you need to make changes after you have submitted the application, contact the Center for Education Placements & Partnerships, Town Point, Room 4230 - (770) 423-6734.
   

• Note on Bartow County Placements: Bartow County Schools require you to be fingerprinted and processed through their Human Resources Department. There is a cost of $45 for this service, only payable in cash or money order. For more information or to set up an appointment, please contact Angela Farmer, the Bartow County Human Resources contact, at 770-606-5800 ext 3855. Currently appointments are only made from 8:30-9:00am on Tuesdays. Please plan ahead and be aware that this time could change.

  
   

You will print 3 copies this request after you have submitted on the next page. To complete your placement request, deliver a hard copy of the confirmation you will receive on the next page, a copy of your transcript, a copy of your tort liability insurance card or other proof of tort insurance, and a copy of the Criminal History Consent Form to the CEPP.