Libs School Site Declaration Form
ADVERTISEMENT
1CALIFORNIA STATE UNIVERSITY, STANISLAUS
One University Circle Turlock, California 95382
Department: (209) 667-3749 Fax: (209) 664-6610
LIBERAL STUDIES: 2000, 2010 and 3000
LIBS School Site Declaration Form
PLEASE PRINT
Name of Student: ________________________________________________ Student ID: ________________________
Student Address: __________________________________________________________________________________
Street
City
State
Zip
Phone: (_____)________________________ Email: _____________________________ Date of Birth: ______________
Liberal Studies Course:
LIBS 2000
LIBS 2010
LIBS 3000
Libs Instructor: ___________________________
Position:
Paraprofessional
Volunteer
Other (specify) ___________________________________________
Student/Teacher fill out completely
Site Mentor Teacher: ______________________________ Email: _______________________________ Phone: __________________________
School Site: ____________________________________ Grade/Age/Placement: ______________ Planned observation hours: _______________
Full name of school
School Address: _________________________________________________________ School District: __________________________________
Street
City
State
Zip
Attendance Record: __________________ _________________ Number of hours observed/tutored per week: ____________________________
From
To
The signatures below verify that the following required elements exist at this placement:
The university student works directly with elementary aged students in a public or private classroom for a minimum of 30 hours during the
semester. (Please note: private school observation may only count for 50% of total hours).
The classroom has 25% or more language diversity.
There is a credentialed classroom teacher who works directly with the university student as a supervisor and will verify the hours on the
observation log.
There are opportunities for the university student to meet with the teacher or other staff members to gain more information at the site.
The university student meets one-on-one, in small groups, or with the entire class. The university student works with or observes the same
students on a regular basis to view their development progress over time.
Student Signature: ____________________________________________ Date:_____________________________
Teacher Signature: ___________________________________________ Date: ____________________________
School Administrator Signature: ________________________________ Date:_____________________________
For LIBS Instructors Use Only
TB Cleared:
Yes
No
Date: _____________________
Livescan Cleared:
Yes
No
Date: _____________________
Comments:
SH: 02/01/10
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal