Practicum Form "*" indicates required fields Step 1 of 3 33% All applications must be filled out completely, or they will not be processed. Questions regarding the practicum policy can be directed to the Director of Teacher Education or designated contact.Name* Mr.Mrs.Ms. Prefix First Middle Last No more than 4 weeks prior* In accordance with the JMU Honor Code I confirm that I am completing this form no more than 4 weeks prior to my practicum. JAC card #* Program*ARTDANCECED-MATELEDFLEDIECEMIEDMUEDPHETESEEDSPEDTESLTHEA Email* Emergency Contact Name* First Last Emergency Contact Phone Number*Practicum Course(s) (and Placement(s) if known)* Have you ever been convicted of, or entered a plea of guilty or no contest to, a felony?* Yes No Have you ever been convicted of, or entered a plea of guilty or no contest to, a criminal offense in another country?* Yes No Have you ever been convicted of, or entered a plea of guilty or no contest to, a misdemeanor involving a child (minor) or a student?* Yes No Have you ever been convicted of, or entered a plea of guilty or no contest to, a misdemeanor involving drugs (excluding offenses related to alcohol or possession of one ounce or less of marijuana)?* Yes No Please explain, and give dates of conviction, type of conviction, and jurisdiction where convicted*Have you ever been the subject of a founded complaint of child abuse or neglect by a child protection agency?* Yes No Have you ever had a teaching, administrator, pupil personnel services, or other education-related certificate or license revoked, suspended, invalidated, cancelled, or denied by another state, territory, or country; surrendered such a license or the right to apply for such a license; or had any other adverse action taken against such a license? Please note: This includes a reprimand, warning, or reproval and any order denying the right to apply or reapply for a license.* Yes No Have you ever had a teaching, administrator, pupil personnel services, or other education-related certificate or license revoked, suspended, invalidated, cancelled, or denied by another state, territory, or country; surrendered such a license or the right to apply for such a license; or had any other adverse action taken against such a license? Please note: This includes a reprimand, warning, or reproval and any order denying the right to apply or reapply for a license.* Yes No Have you ever left any education- or school-related employment, voluntarily or involuntarily, under any of the following circumstances: (1) while the subject of a review, inquiry, investigation, or appeal of alleged misconduct; (2) when you had reason to believe a review, inquiry, investigation or appeal of alleged misconduct was under way or imminent; or (3) while any administrative or judicial proceeding involving an allegation of misconduct was pending, eligible for appeal, or under appeal? Please note: This includes any open investigation by or pending proceeding with a child protection agency and any pending criminal charges.* Yes No If you answered “Yes” to any of the above questions contact the Director of Teacher Education or appropriate designee.A practicum/clinical field experience is defined as a field experience for teacher candidates to develop and demonstrate their knowledge, skills, and professional dispositions in a variety of settings that are appropriate to the content and level of their program. Teacher candidates can develop proficiencies through observation, instruction, tutoring, and active participation in their assigned placement. The safety and security of the school community is a top priority of the MidValley Consortium. Anyone convicted of a misdemeanor or felony offense, especially an offense against a minor, may be disqualified from volunteering depending upon the nature of the offense and/or volunteer activity. The statements made by me in this application are true and complete to the best of my knowledge. I understand that any willful misstatements or material omission on this application will be considered sufficient cause to disqualify me for volunteer opportunities. During such times as I am a participant in a field experience, I agree to assume full responsibility for such participation and release the school division from any damages which I may sustain thereby. I fully understand that if services are no longer needed, or my performance is not acceptable, the school or division and/or my college/university has the right to terminate my services as required without notice.Signature*Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
