OBSERVATION ONLY 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 Address: 

Street Address: 

City:

State:

Zip Code:

Total Hours Needed: 

Please indicate the CHIME site at which you would like to do your observations:
Class for which you are doing your observation:
(Please specify Department and class number, e.g. SPED 401A.)
Number of visits requested, and number of hours per visit:
 (E.G. 4 visits, 2 hours each)
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.)
Other considerations:
(For example, do you need to observe in a particular setting? Is an interview with the teacher required? Do you need to observe a child of a specific age?)
What is the purpose of your observation?

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