RESOURCES FORM INTERNSHIP A.1 INTERNSHIP & FIELD PLACEMENT FORM Information obtained from this form will help keep our database up to date. Please PRINT CLEARLY and submit to Mr. 'Naltan Lampadan, Faculty of Education & Psychology Internship Supervisor a week before the internship begins. SECTION A: STUDENT Student's Name: _Siaa = Student D:_2o1a0o240 Faculty & Major: _ Eduycection Semester & Year 4, 20)8-Maq Email Address: _Sinhsong}3@geril-com Phone No: __OSSO8SSO Course Codes:_ EDUC 460. Date of internship (duration) _Augurt_ YL Decambet Student's signature: ‘SECTION B: COLLABORATING TEACHER Colaborating Teacher's Name: Swama Alay trait Seema@saims-ac-th Phone: O&4 77098 24- Qualification: NM]. A Teaching Experiences: 20 Name of schoo! 5 hassel eional “Mason Sch, Adcress of school: Ma3 Hyak sl Collaborating Teacher's signature: _—__SECTION C: SCHOOL ADMINISTRATOR emai: gfe ster@ arens.aeth School Administrator’ Signature This information given is considered confidentif( and will not be used in any way other than to reach you regarding ‘ation forthe internship program or concern about our students. Thank you for your understanding and. cooperation Ifyou have questions or reservation about this placement, contact the university supervisor, ‘alton Lampadan MB 096132657, Office Ext. 1168 PLEASE NOTE: if any changes are made to your field placement, you are required to inform your internship program supervisor immediately via-email and must re-submit this confirmation. Thank you!