CFM 216: Discipleship Practicum Application Form

CFM 216: Discipleship Practicum Application Form
Connect with Dan Haase, CFM Department Chair, to learn how to properly engage the CFM 216 syllabus here before submitting your application.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Student ID Number*
ex. 12345
Email*
example@example.com
Academic Advisor*

First NameLast Name
Practicum Begin Date*

MonthDayYear
Date
Practicum End Date*

MonthDayYear
Date
Which semester is your Practicum taking place? (check all that apply)*

SummerFallSpring
The Discipleship Certificate requires 2 practica, and this is my:*

Second
Practicum Title*
Practicum Site Name*
Practicum Site Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practicum Site Supervisor*

First NameLast Name
Practicum Site Supervisor Contact Number*
Please enter a valid phone number.
Practicum Site Supervisor Email*
example@example.com
Student Signature*

Clear
Date*

MonthDayYear
Date
Practicum Vision Statement*
Identify why you are entering into this discipleship practicum and what you hope to accomplish or learn by the end of your experience.
CFM Objective Completion*
Self-select 3-6 of the 9 objectives from page 2 of the syllabus (see chart with academically grounded, spiritually maturing, and practically skilled categories). Construct specific and tangible ways you will address the objectives you've selected ("I know [state objective] will be met when evidenced by...[insert your stated commitment]").
Practicum Advisor Signature

_______________________________________________________
Should be Empty:

CFM 216: Discipleship Practicum Application Form

Practicum Advisor Signature