Graduate Practicum Application - Holy Family University Page 2
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1
2Placement Request Information
Transportation is your responsibility. Do you rely on public transportation?
Yes
No
Have you been formally accepted to the School of Education?
Yes
No
Placement Request at Place of Employment
Complete this section if you are employed in a school setting and are requesting to complete your Practicum
at your place of employment.
School Name _______________________________________________________________________________________________
Address ___________________________________________________________________________________________________
Principal’s Name _____________________________________________________________________________________________
Phone ____________________________________________ Email __________________________________________________
Principal’s Signature ______________________________________________________
Date ______________________________
Clearance Requirements
This form must be completed and copies of current clearances must be registered with American DataBank
at Please note that clearances are valid for a period of one year from date of issue.
Required clearances are:
• Tuberculosis Test
• Act 151: PA Child Abuse
• Act 34: PA Criminal Background Check
• Act 114: Federal Criminal History Record (fingerprinting)
• Act 24: Arrest/Conviction Report and Certification Form
Note that clearance requirements in New Jersey and select Pennsylvania districts may differ. Students placed in New Jersey must register
PA clearances with American DataBank and contact their host NJ district or school to determine and meet local clearance requirements.
Signature
By signing this application, I (the applicant) certify that the information submitted is true and complete.
I understand that false statements herein will subject me to the possibility of dismissal from the School of Education.
Student Applicant Signature: _______________________________________________________
Date: _______________
Return this completed form to:
Field Placement Office
ETC 438/441
Holy Family University
9801 Frankford Avenue
Philadelphia, PA 19114
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