Field Based Program Application

Early Field Experience

Please fill all of the following completely. (Use proper capitalization. Do Not use ALL lower case letters or abbreviations)

Application Date : - -

*Semester:         *Campus Wide ID#: *Social Security#:  - -
*Last Name :    
(Use proper capitalization)

*First Name:  
(Use proper capitalization)

Maiden Name:    
*Ethnicity:               Race1    Race2 
*Date of Birth:   - - *Gender:     
(Use proper capitalization)  

(Use proper capitalization)


*Home Phone:    *Alternate Phone:  Fax #:            


*Level of certification:

*Teaching Field:        

Note: 30 hours will be the maximum of hours required. For example, if you are enrolled in both ELED 300 and RDG 350 you will only be required
to complete 30 hours of observation.

*Course #1:          *Instructor for Course #1:

Course #2:          Instructor for Course #2:

Course #3:          Instructor for Course #3:

Course #4:          Instructor for Course #4:

Campus (indicate the campus where you are receiving instruction):

Are you currently an educational aide?

Note: If "Yes" stop at this point and submit the application.

Note: If you are an educational aide, you may fulfill your field experience while on-the-job, at your current place of employment, provided it is in a
TEA-accredited school.



Please indicate what district and campus you would like to observe. You may choose any school district that is TEA recognized. You must spell out the district choice.
Please type in the following format: Dallas ISD (not  DISD or Dallas), Paris ISD (not PISD or Paris). If you fail to spell your district choice correctly your application will not be processed.

Note: You may not observe a classroom in which a family member is a student and/or mentor teacher.
Note: You are not guaranteed to receive your 1st district and/or 1st campus choice.

1st District Choice:  
Campus:No Preference
             Type in request  

   Mentor: No Preference
                Type in request 
2nd District Choice: 
Campus:No Preference
             Type in request  

   Mentor: No Preference
                Type in request 

Grade Level: No Preference
                    Type in request

Are you currently enrolled in a TECA Navarro Partnership class?

I fully understand that I am not permitted to contact the school district regarding placement.
All placements will be made by the Teacher Certification office.

I fully understand that I must submit my Criminal History Investigation form,DPS Audit form by 8:00 AM on Thursday, September 17h,  2015  or my
 observation application will not be  processed and I will not receive an assignment. 

 Note: Incomplete applications  and will not be processed  and will result in delaying your observation assignment.

FERPA Consent to Release Educational Records and Information

This release represents your consent to permit Texas A&M University – Commerce to disclose educational records and any information contained therein to the specific individual(s) identified below.  Please read this document carefully.  

I am a candidate at Texas A&M University – Commerce / Educator Certification Program and hereby give my voluntary consent to officials: 

A. To disclose the following records:
           •    Records relating to any of my field-based experiences
           •    Records relating to my performance in the field
           •    TExES test score results

B. To the following person(s):
           •    School districts or other agencies associated with field-based experiences
           •    School-based/Agency-based administrators
           •    School-based/Agency-based cooperating teachers/mentors
           •    Program faculty
C. These records are being released for the purpose of:
           •    Conversing and reviewing performance
           •    Acquiring feedback
           •    Procuring required signatures

I understand that under the Family Educational Rights and Privacy Act of 1974 (“FERPA” 20 USC 123g; 34 CFR 99; commonly known as the “Buckley Amendment”) no disclosure of my records can be made without my written consent unless otherwise provided for in legal statutes and judicial decisions.  I also understand that I may revoke this consent at any time (via written request to the educator preparation program) except to the extent that action has already been taken upon this release.  Further, without such a release, I am unable to participate in any field-based experiences including 30 clock hours of observation, clinical teaching, student teaching, or internship.   

*Please select if you understand FERPA Consent