Liberal Studies 3000 School Site Declaration Form printable pdf download

CALIFORNIA STATE UNIVERSITY, STANISLAUS

801 West Monte Vista Avenue  Turlock, California 95382

Department: (209) 667-3749  Fax: (209) 664-6610

LIBERAL STUDIES 3000 School Site Declaration Form

PLEASE PRINT

Name of Student: ___________________________________________________ Student ID: __________________________________________

Position:  Paraprofessional  Volunteer  Other (specify) __________________

Libs 3000 Instructor: ____________________

Student/Teacher fill out completely

Site Mentor Teacher: __________________________ Site Mentor Teacher Email: ____________________________________________________

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

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.

School Administrator Signature: ______________________________________ Date: ________________________________

In addition, the student will meet the academic requirements of this Service-Learning experience

through the following:

 While volunteering in an elementary classroom, the student will observe and work with students and the classroom teacher. The

student will complete daily field notes focusing on course themes of motivation, assessment, management, and diversity.

 The teacher will complete an assessment.

 The student will complete written assignments connecting the observations to the course themes.

 The student will keep personal elementary student information confidential. Reporting of the volunteer experience should avoid

the use of personal names

Student Signature: __________________________________________________ Date: ________________________________

Teacher Signature: __________________________________________________ Date: ________________________________

For Instructor’s Use Only

Comments:

TB Cleared: Yes No

Date: _____________________

Livescan Cleared: Yes No

Date: _____________________

CD: 01/23/13

Liberal Studies 3000 School Site Declaration Form

Related Articles

Related forms

Related Categories