Out of Area Student Teaching Request

Please use this form to request permission to student teach outside the Brockport area.

Name Name First Last
Phone Phone - ### - ### ####
Brockport Email
Program

Program Early Childhood or Childhood Inclusive Adolescence Education
Current Cumulative GPA
Student Teaching Semester
Please explain why you are requesting permission to student teach outside the Brockport area.
Please upload supporting documentation here.
maximum 5 files whose total size may not be more than 10MB
filenames should not contain more than one period (.)
What courses (if any) do you still need to complete?
What workshops (if any) do you still need to complete?
If your request is approved where will you be traveling from? If your request is approved where will you be traveling from?
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
If your request is approved are there specific districts or other placement preferences you would like us to consider?