Applications are due in School of Education Student Services Office (1st floor, Founders Hall, Room 1110) by
Friday, January 31st, 2014

A. Please select from one of the options below (students must complete a SEPARATE application for each experience)

1. General Information

2. Will you be living on campus?

3. If yes, list campus address if different from above address:

4. School attended (include city and state)

5. CONFLICT OF INTEREST: Candidates are placed in schools for field experiences and student teaching within a 40 mile radius of the University; however, candidates may not be placed in schools in which they have a potential conflict of interest.  Conflicts to be avoided are schools in which the candidate has attended, has relatives employed or attending or has any other potential conflicts that may impact his or her placement at the school.  Please list any schools within a 40 mile radius of SIUE in which you may have a potential conflict of interest and the type of conflict. 

6. HARDSHIPS: Please list any schools/districts/areas within a 40 mile radius of SIUE that would pose a hardship and describe the type of hardship.  Hardships might be driving distance from your home, schools that do not have special accommodations to meet your needs, distance from daycare, etc.  School of Education Student Services Office cannot guarantee you will not be placed in any schools listed but we will work to best accommodate your needs within the program parameters in seeking a field placement.  Please take notice that School of Education Student Services Office will not make changes after placements are established. 


7. By submitting this application, I give consent for SIUE to share any educational records, background check information and drug screening information with school partners.

BACKGROUND CHECKS: All students must have a background check clear of all enumerated offenses on file in School of Education Student Services Office before a placement will be confirmed. Students needing information about the background check should visit

Should the information contained in the background check change, it is their obligation to inform School of Education Student Services Office. Changes in criminal history could impact future placements and/or eventual certification.

Any questions regarding your placement may be directed to Lindsey Loyd at 650-3940 or e-mail