Southwest Minnesota State University
Special Education Graduate Practicum Experience Application

Complete one application for EACH practicum.  A hold will be placed on your practicum registration until your practicum is approved. You must be admitted to the graduate program and have completed the Special Education Courses before you can begin a practicum.
I. Personal Information

Name _________________________________________________ License File No. ____________________________

Your Address _________________________________________________________ Phone # ____________________

City, ST Zip     ___________________________________________ E-mail Address ____________________________

Mustang ID _____________________________________________  

	Have you been convicted of a crime other than a non-alcohol related traffic violation?

	No ____    Yes ____   If “yes,” attach material indicating the crime of which you were convicted, 			including the court in which you were convicted, dates and sentence imposed.
II. Requirements for practicum/Special Education Licensure 
	____ I am covered by liability insurance for all placements
	____Yes, name of insurer__________________
	____No - If you are not currently covered by liability insurance you must join 					    EMSP for liability coverage
	
NOTE:  Most school districts have a background check process.  Check with the school district PRIOR to your beginning date.
III. SPED Practicum Experience 
	Check one:
_____	670 ASD (mild-to-moderate)	               _____	680 ASD (moderate-to-severe)
_____	681 DD (moderate-to-severe)		
_____	673 EBD (mild-to-moderate)	            _____	683 EBD (moderate-to-severe)
_____	674 LD (mild-to-moderate)	              _____	684 LD (moderate-to-severe)
	
Semester/ year of practicum enrollment: 

	______Fall	_____Spring	_____Summer	    Year: 20 _______

IV. Placements – EBD, LD, DD in K-4, 5-8, 9-12; ASD in Birth-gr. 4, 5-8, gr. 9-age 21
CAN be in the same site if all levels are available with a mentor teacher licensed in the correct field. 
INCLUDE a copy of each mentor teacher’s license, available at https://public.education.mn.gov/LicenseLookup/educator 

A.  First Placement - Elementary:       _____ Check here if all placements have same site/mentor

School Name ___________________________________ Phone Number__________________________

School Address ________________________________________________________________________

SPED Mentor Teacher _____________________________License File No.________________________

Building Administrator _____________________________ Phone number_________________________

B.  Second Placement – Middle Level:  

School Name___________________________________Phone Number___________________________

School Address ________________________________________________________________________

SPED Mentor Teacher _____________________________License File No.________________________

Building Administrator _____________________________ Phone number_________________________

C.  Third Placement – High School Level:  

School Name___________________________________ Phone Number___________________________

School Address ________________________________________________________________________

SPED Mentor Teacher _____________________________License File No.________________________

Building Administrator _____________________________ Phone number_________________________

Student Signature __________________________________________     ____________________
                       		Practicum Candidate           			 Date              

Practicum Instructor Signature _______________________________     ____________________  
                                            	Instructor                                 Date                            	                
Assessments will be completed online through Livetext 

              Director of Placement and Licensure
1501 State Street, IL 150
Marshall, MN 56258
Contact Information: 507-537-6152 or 1-800-642-0684 ext. 6152