College of Education

Intent for Clinical Participation

This form should be submitted prior to the deadline for Residency or Student Teaching. Please click here for more information.


Please Complete All Fields.

I am planning to participate in:   



First Name
Last Name
Middle Name
Previous Name (Maiden name or other previous name)
TNumber  (ex. T00001234)
TTU Email  (ex. IMStudent42@students.tntech.edu)
Local Address
City
State
Zip Code
Primary Phone Number (ex. 931-123-4567)
Alternate Phone Number (ex. 931-123-4567)
Date of Birth (ex. 01/01/1990)
Gender
Attending Campus

Your Proposed Plan

When do you plan to begin Residency or Student teaching? (Not Current Term)

Semester
Year
Licensure Area (Teaching Field)
High School Attended
Have you filed your TTU Graduation Application with the TTU Graduation Office?
Emergency Contact Information:
Full Name of Emergency Contact
Emergency Phone Number (ex. 931-123-4567)
Emergency Email
Relationship of Contact to You


List any pertinent information that you feel is important for the TTU Office of Teacher Education to consider when making your placement for your clinical experience (i.e. health concerns or limitations, pregnancy, etc.)

Select two school systems where you would like to complete your clinical experience. While your preferences are taken into consideration, they cannot be guaranteed. If you are completing this form for Residency 2, please do not select a school system.
First Choice
Second Choice
   



College of Education