Clinical Practice Application

MAT/Post-Bac Candidates:

Must have taken and passed all of the appropriate content test(s) before beginning Clinical Practice. Please request that scores are sent to ODE & Muskingum University.
Date Taken:
All Candidates:

Must have had BCI and FBI background checks completed within one year of beginning clinical practice. A copy of BCI and FBI background reports must be submitted to Linda Huston at least three weeks prior to beginning Clinical Practice.
Date Taken or Scheduled:
MAT/MAP/Post-Bac Candidates:

Must have taken and passed the appropriate content test(s).
I have taken and passed the appropriate content test(s):

YesNo
MAE Candidates:

Must have taken and passed the appropriate content test(s) before applying for licensure.
I have taken and passed the appropriate content test(s)

YesNo
All Candidates:

Must complete a Graduation Audit with Mrs. Nancy Bradley (Mrs. Marjorie Pickworth –MAP) prior to the beginning of Clinical Practice.
Date Scheduled:

MonthDayYear
Date
Date Completed:

MonthDayYear
Date
All Candidates Currently Working in a District: Please list current job information.
Current Role:
Current District of Employment:
Current School of Employment:
Principal:
Principal Email:
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:

Area CodePhone Number
Do you expect to student teach where you are currently employed?

YesNo
If Yes, please provide:
Teachers Name:
Teachers Email:
example@example.com

Your information may be shared with potential placements upon their request.

Candidates Not Currently Working in a District:
Please list below your 1st, 2nd, and 3rd preferences for Clinical Practice. You may NOT request a specific teacher. Although we take all of your choices into consideration, we CANNOT guarantee a placement in any given school.
District (1st Choice):
School:
Principal:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:

Area CodePhone Number
District (2nd Choice):
School:
Principal:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:

Area CodePhone Number
District (3rd Choice):
School:
Principal:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:

Area CodePhone Number

Please briefly outline your career objectives, telling us what you hope to bring to the educational setting:
Please briefly describe your background, including your initial degree(s), hobbies and professional interests:
Should be Empty: