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College of Education
Graduate Practicum Application

General Data:
Name (last, first, middle initial):

NU ID number:

Home Telephone: Work Telephone:

UNO e-mail address:

Present Street Address :

City: State: Zip Code (9 digit):

Placement Request Data: Semester Requested:

I am registering for: Dept Course #

Check the Area of Practicum for Which You Are Applying

Special Education Teacher Education
Behavior Disordered Early Childhood Education
Deaf / Hard of Hearing School Library Media
Learning Disabled English as a Second Language
Mildly / Moderately Disabled Middle Level
Speech-Language Pathology Dual Language
Counseling Other

Check the (ONE) Site to Which You Are Applying:

School Site Library Site
Medical Site UNO Clinic

Complete the Setting and/or Level You Are Requesting Placement :

Site (Medical or Library)
*District School Elem (or) Sec

*Note: Boys Town placements require special training and scheduling arrangements. Please contact your advisor for information

Approval Signatures (Obtain in the order indicated)

Student _______________________________________ Date __________

Advisor _______________________________________ Date __________

Department Chair ________________________________ Date __________

Coordinator of Field Experiences_____________________ Date __________