FIELDWORK REQUEST FORM

In order to process your request for an observation experience at the CHIME Charter Schools, we need the following information from you:

Complete all fields. If you are unsure of any of the information, please look at your class syllabus or assignment sheet in more detail, then return to the site. Your request will not be processed if there is information missing.

Name:

Home Phone:

Daytime Phone:

Cell Phone:

Email:

Street Address:

City:

State:

Zip Code:

Total Hours Needed:

Please indicate the CHIME site at which you would like to do your observations: (Please specify Department and class number, e.g. SPED 401A.)
Class for which you are doing your observation/fieldwork: (E.G. 4 visits, 2 hours each)
Number of visits requested, and number of hours per visit:
Specify days & times available:
 (Please note: If you need to do a large number of fieldwork hours we will be unable to accommodate you unless you can commit to a regular schedule of hours each week.)
What type of work do you need to do with the students?
(Please be specific: e.g. present 2 lesson plans, do an informal assessment, etc.)
With how many children do you need to work?
(Be specific: do you need to work with just one child, two or three different children separately, small groups, etc.)
Other considerations:
(For example, do you need to work with a specific age of child? Do you need to work with a child with second language issues or special needs?)

Once your form has been submitted, click on continue on the next page