CLINICAL EDUCATOR REGISTRATION – INTERN/STUDENT TEACHER
A Certificate of Participation will be issued to each clinical educator for his/her participation after hosting a full time student teacher/intern. It entitles the recipient to register at any state university in Florida without payment of tuition for ONE semester for up to six semester credit hours. The certificate is NON-TRANSFERABLE. Please secure it in a safe place as lost certificates cannot be replaced.
To insure that you receive a Certificate of Participation from Florida Atlantic University please complete this registration form and return it to Florida Atlantic University’s Clinical Experiences Office in the College of Education.
Semester: _______ Fall ______ Spring Year: _________
Clinical Educator Information:
Name ___________________________ Social Security # (Required by State) _________________
Phone # Professional Email Address ______________________________________
Mailing Address
District ___________________ School Name _______________________
School Address
Developing Teacher Information:
Name ________________________________ Z#
Major: ____ Elementary ____ Secondary ____ ESE Practicum ____ ESE Internship
I certify that I have either attended an orientation meeting for Clinical Educators within the last twelve months or reviewed all materials available on the FAC Clinical Educator Orientation web page at the start of the current semester.
______________________________________ __________________
Clinical Educator’s Signature Date
Please FAX or SCAN this registration form to the Office for Clinical Experiences:
Palm Beach, Indian River, Okeechobee, St. Lucie, Martin
Fax: (561) 297-2991 or Email: [email protected]
Broward and Miami-Dade Counties
Fax: (954) 236-1022
Certificates are issued only once per semester. In order to use the certificate for Spring enrollment you must submit this request no later than October 31st. In order to use the certificate for Summer or Fall enrollment you must submit this request no later than April 30th
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