Clinical Experience Placement

Complete the following form for Clinical Experience Placement.

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All fields marked with an asterisk (*) are required.

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First Name*

Last Name*

DuPage Email address (lowercase only)*

7-digit Student ID (not SSN)*

Clinical Placement Semester*

Course currently enrolled in (select all that apply)*

EDUCA 1100 Introduction to Education

EDUCA 1101 School Procedures

EDUCA 2201 Education for Exceptional Children

Course Instructor(s)*

Do you plan to participate in the Bensenville Care Program?*

Yes

Do you need assistance in finding a Clinical Placement?*

Yes

Clinical Placement District*

Clinical Placement School*

Clinical Placement Grade*

Clinical Placement Teacher*

Hours anticipated this semester*

Did you plan to have more than one placement this semester?*

Yes

If yes, complete the following form fields:

Additional Clinical Placement District

Additional Clinical Placement School

Additional Clinical Placement Grade

Additional Clinical Placement Teacher

Additional hours anticipated this semester

Email April Zawlocki at College of DuPage (zawlockia@cod.edu) with any questions.