POLICY RESPO= NSE FORM

DIRECTIONS: &= nbsp; Please complete this form and return it to your University Supervisor by the end of the first week of your field experience.

Students who do not complet= e and return this form may be denied the opportunity to participate in their field experience.

Student Name__________________________________________________________________

Social Security Number or Kean ID Number _________________________________________

Course Number ________________________________________________________________

Supervisor Name _______________________________________________________________

Semester _____________ Professional Internship ___ OR Preprofessional Experience _= __

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I have read my respective= Guide for Professional Laboratory Experiences: Professional Internship Handbook III or Preprofessional Field Experience Handbook II and agree to abide by the policies and procedure= s of Kean = University, the College of Education and the Teaching Performance Center<= /st1:PlaceType>, as well as the policies and procedures of any school districts throughout t= he placement experience.

I have read Section VIII,= Part B: State of New Jersey Requirements for Educators – Criminal History Background Check and Disqualifying Offen= ses in my respective handbook and understand that if I have been convicted of or have any charges pending, as defined, that I will be denied the opportunity= to participate in or complete my field work and, in most cases, will be denied= a teaching certificate from the State of New Jersey.

I also understand that Ke= an University reserves the right to remove candidates from their preservice placements at the district/agency&#= 8217;s request or by Kean University, College of Educatio= n administrative decision. I am= aware that the professional internship and the preprofessional field experience m= ay be repeated only once provided all recommended interventions are met and th= at formal application to repeat the field experience must be made to the progr= am advisor two months prior to the start of the requested semester.

____________________________________________________ &= nbsp; __________________

&nbs= p; Student Signature &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; = Date

University supervisors are to forward the original of this form to =

the Teaching Performance Center upon receipt.