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Student Name

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Site (full name)

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2. Address

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Clinical Site Information

Education 1100

Grade

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4. Cooperating Teacher

Site Administrator
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SitePhoneNumber

7.

Secretary name

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8. Dress and appearance

Policy

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9. Meeting Day(s) and Times Scheduled

10. Contact person for absences

11. Students

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Note: Students should return this complete form in to the instructor by

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