Field Laboratory Intake Form

Educational Leadership Program EDUC# 364, 367, 370

Field Laboratory – Intake/ Form

Name on SCU Records: Student ID#

SCU Email:

Mailing Address: City: Zip:

Contact Phone Number:

Home Address:

Employment/District/School/Other or agency of employment:

Address:

Phone Number: ( )

Your title-What do you lead or administer:

Other responsibilities?

Project Supervisor’s Name:

Supervisor’s Number: ( )

What major tasks/projects/cycle will you be accomplishing during this quarter at your place of employment?

What signature assignments or major projects have you completed in the program so far?

Student Signature:

Supervisors Signature:

Comments:

Date of Approval: Date of Completion:

Educational Leadership Program EDUC# 367, 370

Leadership Field Laboratory – Intake/ Form Part 2

What CPSEL/CAPE Standards will your current project be addressing? (Please specify specifically by standards) How do they apply to your project?