Course Number/Section ______________



SUNY ORANGE
FIELD OBSERVATION/FIELD PLACEMENT
STUDENT INFORMATION/RELEASE FORM


Student Name ___________________________________________________________

I have read and understand my responsibilities regarding field work as stated in the course syllabus.


____________________________________________	________________________
Signature						      	Date

Home Phone Number ____________________________________________________

Cell Phone Number ______________________________________________________

Email Address __________________________________________________________






I hereby grant permission for employees of SUNY Orange to release my name, address and telephone number to the administrators of the school, school districts, or other educational or child care facilities in which I may be placed as a student observer in conjunction with my participation in the Education Department field sites, program and related courses.

I further agree to notify the Coordinator of the Field Placement Program in writing should I wish to rescind this permission.



__________________________________________	________________________  
Signature							Date



Revised 08/03/10