Internship Agreement

Lamar University – Superintendent Certification
Application for 9-Month Superintendent Internship Program (Field Experience-Practicum) and Mentor Application and Agreement:

Directions:

• After completing the Application, submit to your  Electronic (TK20) Field Experience Binder.  Submit the completed application with electronic signatures.

Date:   __9/13/2011________

Name:  ___Randall Scott Nedrow_______________________ Student ID#: _L20118038_______  SS#:_xxx-56-6709____________

Address: 2111 Serene Court_________________________            City: __Keller,Texas_______________ Zip: _76248______

Phone: (___)___N/A_______  Cell Phone:  (_817__)_683-6695_________ 

E-mail:_rnedrow________ @my.amar.edu                Home E-Mail:  __s_nedrow@hotmail.com__________________

 Field Experience Diversity Information:

Gender:             Female            Male

Ethnicity (mark one): 

        African American            Hispanic            White              Native American

                            Asian/Pacific Islander                          Other

Using information found in the AEIS District Report, report Characteristics of Students who are part of your field experience. This information may be obtained from your district or from TEA’s Accountability Report links.

Ethnicity or culture                           % from AEIS District Report

African American	24.5%
Hispanic	60.5%
White	13%
Native American	0.3%
Asian/Pacific Islander	1.8%
Other

Demographic Information for Students who are part of your field experience:

% from AEIS District Report

English Language Learners	Yes	No	28.6%
Economically Disadvantaged	Yes	No	75.3%
At-Risk	Yes	No	58.5%

Proposed Location of your Field Experience (Internship practicum):

School Name:   __Fort Worth ISD ______________________________________                          

Address: _1411 Maydell Street_______________________  City: _Fort Worth, Texas___________  Zip:________

District:  __Fort Worth ISD___________________     Region:  _13______(  1 – 20)

Site Supervisor/Mentor Agreement

As a site supervisor/mentor, I recommend __Randall Scott Nedrow____________________ for acceptance into the Internship program at Lamar University.  I will provide this graduate student with assistance and opportunities necessary to fulfill the requirements of the Superintendent Internship practicum (field experience), which is to number a minimum of 120 hours. The intern applicant is granted permission, including time when permissible for practical experience, to work toward completion of the Internship under the supervision of a Cooperating Supervising/Mentor Administrator and Lamar University Consulting Supervisor (a member of the Educational Leadership faculty – e.g., Dr. Elvis Arterbury, Dr. Bob Nicks, Dr. Steve Jenkins, Dr. Lu Stephens, Dr. Jimmy Creel, or Dr. Roy Benavides).

Please check:

           The student Intern has given me the Mentor/Site Supervisor Handbook, or provided me with an electronic version.

           The student Intern has discussed his/her needs about the program and I accept.

Signature and Title:  __Clifford Mayer/ Director of Induction, Development and Retention/HCM___________________________________________ Date:__9/13/2011_______

Print E-Mail address for Supervisor/Mentor:   ___clifford.mayer@fwisd.org/_________________________________________________________________________

Mailing Address of Supervisor/Mentor:   3150 McCart Ave., Suite214 Fort Worth, Texas, 76110

____________________   City: _Fort Worth,Texas________ Zip:  _76110____

All intern site supervisors/Mentors must have a Texas certificate in school administration.