Practicum Form 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* 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 anywhere in the United States or a criminal offense in another country or a U.S. territory?* Yes No Have you ever been convicted of, or entered a plea of guilty or no contest to, a misdemeanor involving children (minor) and/or involving drugs (not alcohol)?* Yes No Have you ever been the subject of a founded complaint of child abuse or neglect by a child protection agency?* Yes No Please explain, and give dates of conviction, type of conviction, and jurisdiction where convicted*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
