Student Teaching Placement Request Form

Required Data

Select Your Campus

Select Your Program Area

Student Social Security Number

Student ID (EmplID) - 9 digits ONLY

Select Semester You Wish to Student Teach

UndergraduateGraduate

Have you been fingerprinted?

YesNo

You MUST be fingerprinted to student teach in all schools. You will not be assigned student teaching until you have had your fingerprints recorded.

Student Name Data

Prefix

Student Address Data

Mailing Address

City

State

Zipcode

If you live on campus in a dorm, please fill give us your room number and dormitory name. We also need your on-campus telephone number.

Room Number/Dorm Name

Campus Phone

Direct Contact Information

Home Phone

Mobile Phone

Email Address

For student teachers, we require that you use the email address assigned to you by Long Island University, e.g., mary.smith@my.liu.edu.

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