PLC Program Request Form

Field Experience Request Form

Please complete this form 4-weeks in advance to request a PLC Field Experience for the desired date.
LEAD TEACHER CONTACT INFO
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
School*
Email*
Mailing Address (if not in District 6)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

CLASS INFO
Grade Level*
Total Number of Students*
Number of Student Groups (typically the number of individual classes)*
If more than one teacher, please list their names and emails:
Any accommodations we should address to ensure every student can participate fully? (mobility differences, language learners, neurodivergencies, etc)

PROGRAM REQUEST

Tuesday - Friday only from 9AM - 2PM; check our calendar for availability
Preferred Date #1*

MonthDayYear
Preferred Date #2*

MonthDayYear
Arrival Time*

:HourMinutesAM/PM Option
Departure Time*

:HourMinutesAM/PM Option
Which program type would you like to request*
Click here to view the information guide with lesson descriptions.
What do you hope to achieve by the end of your program? How much of an emphasis do you want on academics and what are some other priorities you have, for example: celebration, exploration, group dynamics, teamwork, etc.*
What will your students be learning about in the classroom in the days leading up to our programming?*
Do you have any specific requests regarding your field experience?
Did you fill out the scholarship form? https://forms.gle/Ze4sjX5UXeKi38z97*
It will take approximately five minutes to complete this form
Should be Empty:

Field Experience Request Form