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Chesapeake College
Education Deparfinent
Each Teacher Candidate must complete a minimum of
15 hours of fieldwork

StudentName f,ac?"+J,Sn Smi-lla Semester-Spsay2 olt


Total Fieldwork Hours Completed i S e.0

Teacher Candidate Signature Date

Cooperating Teacher Signature Krvrcv^. (\rf:rc Date 3- 1- \B

Note: The Cooperating Teacher must return this completed form to the Coordinator of Field Experiences, along
with the fieldwork Log Sheet, at the conclusion of the fieldwork experience. All forms should be mailed in the
envelope provided or to the address below. Thank you for your time and willingness to assist a future teacher.

Dr. Deanna Stock

Education Departurart
Chesapeake College
P.O. Box 8
Wye Mills,I\{D21679