Site Supervisor Partner Request Form | Wheelock College of Education & Human Development

Name*

First Last

Phone (best number to reach you)*

Email*

School Name*

District Name (NA if not applicable)*

School Website*

MA DESE License or MEPID Number*

PLEASE NOTE: Supervising Practitioners must have at least three full years of experience under an appropriate Initial or Professional license and an evaluation rating of proficient or higher, under whose immediate supervision the candidate for licensure practices during a practicum.

Grade Levels (select all that apply)*

Academic field program/s relevant to your licensure area (select all that apply)*

Are you an alum of BU or Wheelock? (select from dropdown)*

How many years of in-service experience do you have?*

Please enter a number from 1 to 40.

Have you supervised practicum students before? (select one from dropdown))*

Student level you are interested in hosting at your school (undergraduate; graduate)? (select from dropdown)*

Practicum type you are interested in hosting at your school (practicum; pre-practicum)? (select from dropdown)*

Does your school or classroom have language specific requirements?*

Please describe (if applicable).

Did you receive a rating of proficient or higher on your most recent evaluation? (select from dropdown)*

Does your school have parking available to students?*

Is your school MBTA accessible from BU Wheelock?*

Tell us why you are interested in hosting BU Wheelock students at your school.*

Is there anything else you would like to share with us about your school?