Clinical 3 Placement Application

Name*

First Last

TAMU Email*

UIN*

Phone*

Primary Certification*

Clinical 3

Select your course/section:*

Semester Clinical 2 was completed:*

Assigned Clinical 2 Campus*

Grade level of Clinical 2 placement:*

Content area(s) of Clinical 2 placement:*

Will you have transportation to your assigned campus?*

How do you plan to get to your assigned campus (carpool, bus, etc.)?

Please list any local campuses where you have observed/worked.

If you have a relative or child at an area school, please list the campus.

Emergency Contact Name*

Emergency Contact Phone Number*

Explain any extenuating circumstances that might affect your placement.

Email

This field is for validation purposes and should be left unchanged.