Student Information

First Name: *

Last Name: *

Middle Name:

Mailing Address: *

City: *

State:

ZIP: *

Date of Birth: *

Phone: *

Email: *

College/University: *

Are you currently employed by BCSD?: *

Yes

No

BCSD Employee ID Number:

School Location:

Please upload a copy of your GCCAE Professional Leave Form. *

View Leave Form

No Leave Form Uploaded

Do you plan to stay in the area after graduation/program completion?:

Yes

No

Placement Requested

Please upload a copy of your current teaching certificate OR Student Teaching Clearance Letter.

View Uploaded Student Teaching Clearance Letter

No Student Teaching Clearance Letter Uploaded

Grade Level: *

Subject/Content Area: *

Term (Check all that apply): *

Fall

Spring

Summer

Start Date: *

End Date: *

College/University Placement Coordinator - Contact Information

Name: *

Email: *

Phone: *

Comments:

School Assignment: Select the schools that you will work with below *

Other School locations associated with this request:

Acknowledgement Statement

By signing below. I understand that this form is for information verification only and that my official placement request must be submitted by my college/supervisor to the Office of Human Resources at Berkeley County School District.

Approval History

College:

Date:

Comments:

School:

Cooperating Teacher:

Grade/Content:

Signature:

Date:

Comments:

Human Resources:

Signature:

Date:

Comments:

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Pending Approval

Student Information

Placement Requested

College/University Placement Coordinator - Contact Information

Acknowledgement Statement

Approval History

College:

School:

Human Resources:


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Pending Approval

Student Information

Placement Requested

College/University Placement Coordinator - Contact Information

Acknowledgement Statement

Approval History

College:

School:

Human Resources: