FIELD OBSERVATION
SPECIAL REQUEST FORM

STUDENT OBSERVER

Name		____________________________________________________________

Home Phone	____________________________________________________________

Cell Phone	____________________________________________________________

Email		____________________________________________________________

Course #/Section _______________________ Date _____________________________

Reason for Request ______________________________________________________

FIRST PREFERENCE

Site Name	____________________________________________________________

Address	____________________________________________________________

Phone		____________________________________________________________

Principal	____________________________________________________________

Host Teacher/Grade	______________________________________________________

GRADE LEVEL/AGE PREFERENCE

Pre-K  _____		K _____	1st or 2nd  _____	3rd � 6th  _____

SECOND PREFERENCE

Site Name	____________________________________________________________

Address	____________________________________________________________

Phone		____________________________________________________________

Principal	____________________________________________________________

Host Teacher/Grade	______________________________________________________

The Field Placement Coordinator will contact the student observer as soon as the request is answered. This does take time depending on the district. Do not contact the host site until we receive official permission. You may contact the Field Placement Coordinator at 341-4486 or 341-4054 with any questions or concerns. Or fax this completed sheet to 344-6230.  Thank you for your cooperation.

Revised 08/03/10