Initial Visit Form

BRIDGEWATER STATE UNIVERSITY

College of Education and Allied Studies, Bridgewater MA 02325

Student: _____________________________________________    check one:   ___ ECPK 481   ____ ECPK 492

School/Center: __________________________________________ Community:_______________________

Program Type:  ____________________________________ For example, group childcare (GCC), family child care (FCC), Head Start, or public preschool/kindergarten.

College Supervisor:___________________________________________________________________________

Site Supervisor: _____________________________________________If no person fits this category, leave blank.

Site  Supervisor’s Years of Experience and Credentials:__________________________________________________

Phone/E-mail/fax Contact Numbers

School/Center: ______________________________________________________________________________

Student: ___________________________________________________________________________________

Site Based Supervisor: _________________________________________________________________________

College Supervisor: ___________________________________________________________________________

Scheduled Supervision Period Minimum of 4 weeks and 100 hours required for a 3-credit experience.  Hours must be spent providing direct services to children, excluding naptimes.  Students should follow the site schedule of holidays and breaks, not BSU’s.

Start Date: _________________________________          Stop Date: _____________________________________

Mon.-Fri. Scheduled Times: _____________________________________________________________________

Misc. information

On ___________________________, ECPK 481/492 requirements and respective responsibilities of the student, the Site Supervisor and BSU Supervisor were explained in a 3-way conference.  The BSU supervisor provided a copy of the course syllabus, written descriptions of course assignments, and scoring criteria to all parties.

Site Supervisor’s Signature: __________________________________________ Date:___________________

Student Signature: _______________________________________________________   Date:___________

College Supervisor Signature: ______________________________________________ Date:______________