Northside Independent School District
Human Resources Department
5617 Grissom Road, San Antonio, TX 78238
(210) 397-8600 / Fax (210) 706-7228

University Practicum / Internship Agreement

An authorization to conduct a criminal history check is required of Northside Independent School District college/university students who will work directly with students. The Human Resources Department will be responsible for conducting criminal history checks. Information obtained will be used solely to determine eligibility for service as a clinical teacher candidate/practicum student.Your completion of this form in its entirety and submission authorizes the Northside Independent School District to conduct investigation inquiries into police records, the state prison system, the Department of Public Safety, and/or any other criminal records to determine your acceptability for clinical teaching or internship/practicum assignment. Failure to clear the criminal history record check as per District policy may disqualify you to serve as a clinical teacher candidate/practicum student in the District.

Note:
A valid email address is required.
Middle name is required: Please check the box if you have no middle name.

DO NOT USE apostrophes or accent characters in your name. (hyphens are acceptable)

* required fields

First Name:*

Phone *
(xxx-xxx-xxxx):

Middle Name:*

Date of Birth * (mm/dd/yyyy):

If no middle name check here

I have no middle name

Enter SSN* (xxxxxxxxx) no dashes:

Last Name:*

Gender: *

Suffix (Jr, IV, Sr):

Drivers License
(If none, type 'none'):*

Email Address;*

Drivers License State: *

Street Number:*

Street Name:*

City:*

Academic Year:*

State:*

Select Placement:

Field observations

Clinical / Student Teacher

Internship

Zipcode:*

Preferred Campus:

This agreement is required for all individuals who will be completing requirements for a college or university class at a Northside ISD facility. You will be able to print a copy for your records AFTER you submit to the Human Resources Department. Acknowledge agreement by checking each box below.

1. Participant agrees to abide by the rules and policies of the District while engaged in any activities related to or associated with Participant's practicum work at the District.

2. Participant acknowledges and understands that no employee-employer relationship exists between the participant and the District.

3. Participant acknowledges not to complete clinical teaching at a campus where their children or siblings attend and/or a campus where relatives are employed.

4. Participant acknowledges the immunity granted school districts regarding personal injury, death and property damage pursuant to Texas Civil Practice and Remedies Code, Section 101.001, et seq., Tort Claims Act.

5. Participant agrees to cooperate with the District in the defense of any claim, suit, or administrative proceeding involving the Participants activity in the service of the District.

6. Any materials and equipment borrowed/issued should be returned to the proper district person at the end of the practicum/observation.

7. All college/university students are prohibited from communicating with students who are enrolled in any district through text and all forms of social media.

8. Participant agrees that student and District information is confidential and shall remain confidential.

9. Participant agrees that they are not to transport District students.

10. Prior to performing any duties at the District, Participant agrees that this form will be submitted to a criminal background check to be conducted by the District, including a national background check (*National inquiries require Participant's social security number and date of birth)

By clicking Submit to HR you are electronically signing this agreement.