Clone of Early Childhood Education Program Clearance Request Form

Early Childhood Education Program Practicum Site Application

This must be completed by the Licensed Director (Classroom Practicum Site) or Parent (Non-Classroom Practicum Site). This application CANNOT be completed by the student.
Practicum Site Information
Name of Practicum Site*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this site handicap accessible?*

YesNo
Name on Childcare License*

First NameLast Name
State Childcare License Number*
Letters + Numbers
Number of Children Cared for at the Site*
Ages of Children Cared for at the Site*
What curriculum is used at this site?*
Mid ECE Student Information
Name of Student Applying to Complete Practicum Hours at this Site*

First NameMiddle NameLast Name
Student's Mid Mich Email*
example@midmich.edu
Practicum Site Licensed Director Information
Name of Licensed Director*

First NameLast Name
Licensed Director Phone Number*

Area CodePhone Number
Licensed Director Email*
example@example.com
Licensed Director's Years of Experience in Early Childhood Care & Education*
Is the student also an employee of this site?*

YesNo
Explain how you will accommodate the student's weekly observation/engagement hours required for coursework.*
Who will be supervising the student?*

The Licensed Director listed above.Another employee at the site.
Site Supervisor Information
Supervisor Name*

First NameLast Name
Supervisor Phone Number*

Area CodePhone Number
Supervisor Email*
example@example.com
Supervisor's Years of Experience in Early Childhood Care & Education*
My signature below indicates that I understand that the student is required to collect ink signatures on the Site Hour Records Form as verification of completed practicum hours. Mid's ECE Program reserves the right to review and verify these signatures at any time.
Signature of Licensed Director*

Clear
Date*

MonthDayYear
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Early Childhood Education Program Practicum Site Application

Practicum Site Information

Mid ECE Student Information

Practicum Site Licensed Director Information

Site Supervisor Information