HRD Request For Field Placement

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This Request for Field Placement must be approved by the Field Placement Contact of the submitting institution. Students should not contact schools or county personnel regarding placements. All requests by school administrators must be made to the Broward County Field Experience Coordinator.

Student Information

To be Completed by Field Experience Student and
verified by the Higher Education Field Placement Contact

* = Required Fields

*College/University:

*E-Mail:

*Last Name:

*First Name:

Middle Initial:

*SSN#:

- -

*Password:

*Verify Password:

*Student Street Address:

*City:

*State:

*Zip Code:

*Student Home Phone:

( )-

Student Cell Phone:

( )-

*Emergency Contact:		*Emergency Phone:	( )-
*Security Clearance Expiration Date:

Additional Information (Questions must be answered.)

*Do you have children attending BCPS?

If yes, where?

*Do you have relatives working in a BCPS?

If yes, where?

*Did you attend a school in Broward County?

If yes, where?

Preferred Information (Every effort will be made to fulfill your preferences but it cannot be guaranteed.)

*Preferred Broward County location?

*Preferred level of students?

*Preferred subject area?

To the best of my knowledge, the information provided in this application is correct.

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