University Supervisor Preference Sheet

First name:	Last name:
Email:	G number:
Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander Hispanic or Latino White Two or more races Race/ethnicity Unknown Do Not Choose to Respond
Current Address:	City:
State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NE NH NJ NM NV NC ND NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	Zip:
Home Phone:	Cell Phone:
Semester: Fall Spring Summer	Year:

University Supervisor Preferences and Qualifications:

1. I am interested in supervising interns in the following grade levels:

• Pre-K
• Elementary
• Middle
• High

2. I am interested in supervising interns in the following programs:

• EDCI 790:
• Biology
• Chemistry
• Earth Science
• Elementary Education
• English
• History/Social Studies
• ESL
• Foreign Language: Arabic

• Foreign Language: Chinese
• Foreign Language: French
• Foreign Language: German
• Foreign Language: Japanese
• Foreign Language: Latin
• Foreign Language: Russian
• Foreign Language: Spanish
• Math
• Physics

• EDSE 790:
• Special Ed: General Curriculum
• Special Ed: Adapted Curriculum
• Special Ed: Visual Impairment
• Special Ed: Applied Behavior Analysis

• ECED 790:
• Early Childhood Education PreK-3 (EPK3)

• EDSE 793/ECED 791:
• Early Childhood Special Education (ECSE)

• THR 455/THR 555:
• Theatre

3. I have teaching experience/endorsements in the following areas:

4. I am willing to supervise students. [Please provide number between 3 (minimum) and 6 (maximum).]

5. I am willing to supervise in the following region(s):

• Alexandria City
• Arlington City
• Fairfax County
• Falls Church
• Fauquier County
• Fredericksburg
• Loudoun County
• Manassas City
• Manassas Park
• Prince William County
• Stafford County
• Washington DC
• Other