Special Education Hours Verification Form

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Please describe your relevant experience(s) paid and unpaid, working with people with disabilities or special needs. This may include working in an early childhood program, in a school, tutoring, camp counseling, working as a PCA, etc.

Note that at least 30 of the minimum 60 hours required should be done in a special education classroom setting.

This form allows you to submit up to three experiences. If you would like to submit more than three, please submit an additional form.

Name (last, first, middle) *

U of M ID number (if known)

Organization name, type of organization, and the person who supervised you

Dates and approximate number of hours that you worked at this organization

Your role and responsibilities

A description of the population you worked with, e.g. racial/ethnic and socioeconomic background, gender, language, religion, geography, sexual orientation, special needs, etc.

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