Viterbo University

Department of Educational Leadership

Practicum Site Agreement

At all sites, the student receives individual supervision from a qualified professional who (a) has
a current principal's endorsement/license and (b) agrees to coordinate, manage, and/or
administrate the students professional preparation activities at the site. This person is referred to
as the Local Building Mentor (LBM). Individual Mentoring involves an average of one hour per
week of one to one supervision between the student and the LBM, and is provided in addition to
the student's practicum related activities as outlined in the practicum prospectus.

Student: Michael Johnson

Course: EDUC 767 Practicum in Educational Leadership

Email Address mj84@charter.net

Phone# 6083864353

Local Mentor (LM) Name:

Email Address: preedy@lacrosseschools.org

Phone#

6087897670

Dr. Penny Reedy

Name and Address of Mentoring Main Site: Longfellow Middle School

Address 1900 Denton Street

City La Crosse

State WI

Zip

54601

Authorization: Your signature below indicates authorization for the student identified above to
participate in an educational leadership practicum at your site as well as your commitment to serve as the
Local Building Mentor for that student.

Local Building Mentor Signature:

Students Signature:

Dr. Penny Reedy

Michael Johnson

Viterbo Advisor Signature:

Date: 12/29/14
Date: 12/29/14
Date:

This form is to be completed, signed by you (the student), your mentor and your Viterbo
supervisor.
This form should be scanned and included in your electronic portfolio.
Send to Jim Bagniewski - jjbagniewski@viterbo.edu