Intent for Clinical Participation

Be sure to submit this form prior to the deadline for your Residency I / Residency II / or Student Teaching as indicated in emails to you.


Please Complete All Fields.

I am planning to participate in:   



First Name
Last Name
Middle Name
Previous Name (Maiden name or other previous name)
T-Number  (e.g. T12345678)
TTU Email  (e.g. IMStudent42@students.tntech.edu)
Local Address
City
State
Zip Code
Primary Phone Number (e.g. 931-123-4567)
Alternate Phone Number (e.g. 931-123-4567)
Date of Birth (e.g. 01/01/1990)
Gender
Attending Campus

Your Proposed Plan
I plan on doing Residency I, Residency II, or Student Teaching in
of Year
Licensure Area (Teaching Field)
Grade Level (Note this is not garunteed)
High School Attended
Have you filed your TTU Graduation Application with the TTU Graduation Office?
Please enter emergency contact information during your clinical experience:
Full Name of Emergency Contact
Emergency Phone Number (e.g. 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. carpooling with another candidate, health concerns or limitations, pregnancy, etc.)

Please choose two school systems that you would like to complete your Residency I or Student Teaching in. Your choices will be considered but not guaranteed. Since you will remain in your Residency I location throughout your Residency II semester, please leave these boxes blank if you are planning your Residency II placement.