EED/MED/SED 203  Phase I -- Field Experience Form (Sophomore Observation Only)

Ask your EED/MED/SED 203 Instructor when the application is due.  If this application is not given to your instructor on the due date, you will be dropped from EED/MED/SED 203 which means that you cannot successfully complete EED/MED/SED 202.

Please select which semester that you will be doing the clinical experience:

  Fall  -or- Spring   Select Year 2002 2003 2004 2005 2006 2007 2007

First Name:      Middle Initial:  
Last Name:  
BirthDate:   /     /     (MM / DD / YYYY)
Social Security Number:  - -

Male / Female:

Male

Female

Ethnic Origin:	American Indian	Asian American
	Alaskan Native	Pacific Islander
	African American	Caucasian American
	Hispanic American	Nonresident Alien

Local Address:
City:     State:     Zip:  
Local Telephone:   ( )   -
Primary E-mail Address (list an address that you access at least twice a week):
 
Name of Advisor:

In keeping with the requirements of Title IX of the education Amendments of 1972 in regard to sex discrimination and Section 504 of the Rehabilitation Act of 1973 in regard to handicap discrimination as well as other applicable federal and state laws, Missouri Western State University follows a policy of nondiscrimination and equal opportunity in regard to all employment practices and to all educational programs and activities including student financial aid, recruitment, admission, housing, and placement. Inquiries regarding the application of these laws may be submitted to Ellen Smither, the Title IX, 504/ADA Coordinator, Student Services/Classroom Building, Room 106. (816)271-4280.