Form

Form 1003*: Practicum-Internship Site Information Form

Fall Semester 2013 Deadline is April 30, 2013.

This form must be filled out completely and submitted at least three (3) weeks prior to phase I registration for the semester you plan to begin field work.

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.

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

Student ID:*

E-mail:*

Full Name:

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Daytime Phone:

- Area Code Phone Number

Evening Phone:

- Area Code Phone 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 Name Last Name

On-Site Supervisor Title:

On-Site Supervisor Phone:

- Area Code Phone 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:

Month Day Year

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