ࡱ> |~{a  $jbjbYQYQ )Z3333 8@4[4dp " !:"s#\2tD3D3D3D3D3D3,5R8p3#!!##p37$ 47$7$7$#8  27$.4b"#27$7$f/p2 %#R42D2+40[4x2D87$827$PURDUE CALUMET SCHOOL OF EDUCATION APPLICATION FOR PRACTICUM OR INTERNSHIP IN SPECIAL EDUCATION (underline one  practicum or internship) Semester to Internship:  FORMTEXT       Program Area: Mild Interventions Name:  FORMTEXT Last,  FORMTEXT First  FORMTEXT Middle Address:  FORMTEXT Street  FORMTEXT City,  FORMTEXT State  FORMTEXT Zip Code Telephone: Home ( FORMTEXT 000)  FORMTEXT 000- FORMTEXT 0000 Work ( FORMTEXT 000)  FORMTEXT 000- FORMTEXT 0000 PUID:  FORMTEXT PUID E-mail Address:  FORMTEXT       In case of emergency, please notify:  FORMTEXT       Relationship:  FORMTEXT       Telephone: ( FORMTEXT 000)  FORMTEXT 000- FORMTEXT 0000 Current teaching assignment: District:  FORMTEXT       School:  FORMTEXT       Date you began teaching:  FORMTEXT       Previous teaching Experience District(s):  FORMTEXT       School(s):  FORMTEXT       Dates:  FORMTEXT       Academic Experiences A. Other colleges attended/degree(s) earned (if applicable) College Degree  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       B. College honors, awards, and/or activities  FORMTEXT       C. Purdue Academic Advisor:  FORMTEXT       D. Grade Point Average (based on 4.0 scale) Major/Primary Area GPA:  FORMTEXT 0.00 Supporting Area GPA:  FORMTEXT 0.00 Supporting Area GPA:  FORMTEXT 0.00 Education GPA:  FORMTEXT 0.00 Cumulative GPA:  FORMTEXT 0.00 E. College Courses Required Courses Completed Prior to Practicum or Internship Title Course and No. Credit  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Additional Information Daily schedule:  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Work experiences related to Education: Employer Job Description Length of Employment  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       I understand the importance of the information I have given in this application and agree to the use of this information by school and university officials in determining my student teaching assignment. 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