Current on website 1/31/18- Clone of Form 1003 - Practicum-Internship Site Information Form

Form 1003: Practicum-Internship Site Information Form

To ensure your site is under contract this form must be submitted at least three (3) weeks prior to phase I registration for the semester if you plan to begin field work.

If you are working at more than one site to fulfill your Practicum/Internship requirements, please submit this form for each of these sites.

Failure to submit this form by the required deadline will result in you being dropped from your practicum class on the last day of phase II registration.

Student ID:*

E-mail:*

Full Name:*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Daytime Phone:*

Area CodePhone Number

Evening Phone:*

Area CodePhone Number

Please enter course information:

Program of Study:*

Course Number:*

Course Instructor:*

You will take selected course:

Semester:*

Year*

Please enter site information:

Practicum Site:*

Practicum Site selected from the Practicum Internship Site List for your program.

On-Site Supervisor Name:*

First NameLast Name

On-Site Supervisor Title:*

On-Site Supervisor Email:*

On-Site Supervisor Phone:*

Area CodePhone Number

On-Site Supervisor Certification/Licenses and Years of Experience:*

Please enter course information:

Scheduled weekly hours at site:*

Schedule*

	Start Time	End Time
Monday
Tuesday
Wednesday
Thursday
Friday

Date Submitted:*

MonthDayYear

You may wish to print a copy of this completed form for your files before submitting. See "print" button below

Please verify that you are human*