Center for Urban Education Special Education Program Apprenticeship Experience Student ____________________________________ Assigned Mentor ________________________________________________

Apprenticeship Assignment (Year One)____________________________________________________________________________________ Apprenticeship Assignment (Year Two)____________________________________________________________________________________ Apprenticeship Assignment (Year Three)___________________________________________________________________________________ Apprenticeship Assignment (Year Four)____________________________________________________________________________________ (Please list additional Apprenticeship Assignments on the back of this form.)

This form must be turned in at the end of each year. Please include a copy of this form in your electronic portfolio. Disability Labels: State Terms Grade Level Year (1, 2, 3, 4) Setting*
Autism Spectrum Disorder Elementary Middle High Deaf-Blind Elementary Middle High Hearing Disability Elementary Middle High Multiple Disabilities with Cognitive Elementary Middle High Impairment Physical Disability Elementary Middle High Significant Identifiable Emotional Elementary Middle High Disability (SIED) Significantly Limited Intellectual Capacity Elementary Middle High (SLIC) Specific Learning Disability (SLD) Elementary Middle High Speech/Language Disability Elementary Middle High Traumatic Brain Injury Elementary Middle High (TBI) Vision Disability Elementary Middle High Other Elementary Middle High *Setting Code: 1 = General Education with Support; 2 = Resource; 3 = Self-Contained; 4 = Other (please define)