Form

Background Information

Final Placements will be influenced by your previous experiences.
List the elementary, middle and high schools you have attended.
Elementary School*
School City Postal Code
Elementary School
School City Postal Code
Middle School*
School City Postal Code
Middle School
School City Postal Code
High School*
School City Postal Code
High School
School City Postal Code

Assignment Preferences

Final Placements will be influenced by previous field experiences.
The Washburn Department of Education is committed to identifying a student placement(s) that will complement your previous experiences and will provide an opportunity to augment your skills and knowledge.
District

Topeka USD 501 Seaman USD 345 Shawnee Heights USD 450 Auburn-Washburn USD 437 Silver Lake USD 372
If you want to request a district not listed above, please provide the district name, location and a brief rationale.
Placement One

K- 6 Elementary

P -12 Elementary

Secondary 6 - 12
School 1st Choice*
Grade Level 1st Choice*
School 2nd Choice
Grade Level 2nd Choice
School 3rd Choice
Grade Level 3rd Choice
Placement Two

Early Childhood Placement

Middle School (5-8)

P-12 Secondary

SPED
School 1st Choice
Grade Level 1st Choice
School 2nd Choice
Grade Level 2nd Choice
School 3rd Choice
Grade Level 3rd Choice
Do you have a child or other relative attending any of the schools identified above? If yes, what are the schools and grade levels of the child and/or relatives?*
Do you have a relative or personal friend employed at any of the schools identified above? If yes, what are the schools and in what positions?*

In the summary comments section please share any additional information you feel is important for the committee to consider in determining your placement.
Summary Comments
Statement of Understanding
Information Related to Criminal Activity
KBI Background Check
TB Test Results
Please attach your resume. Confer with your advisor to ensure the style and form of your resume is appropriate.
Please attach a letter of introduction for your cooperating teacher. Review the instructions on the Reflective Educator Wiki to ensure the style and form of your letter is appropriate.
Additional Placement Information
Enter your advisors name in the space provided. This confirms that you have discussed the information proviided in this application with your advisor.
Enter your advisor's email address.
SUBMISSION of this application AFFIRMS all INFORMATION provided IS TRUE and ACCURATE.
Submission Date
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Background Information