Fall_____ Spring _____ Summer_____ Year ___________

Course #: ___________________ Date Submitted: ____________

PERSONAL DATA (Must match current registration)

Student Name: _________________________ SS#: ____________________

Address: _____________________________________________________________

Street _________________  City  _____________  Zip code _____________

Phone (home): _______________________ e-mail: _____________________

Phone (work): __________________________

How many credits have you completed towards your degree? _________________

 

FIELD PLACEMENT DATA

Beginning date: ____/____/_____ Total hours to be completed: ____________

Expected completion date: _____/____/____ Expected weekly hours:___________

Site Supervisor (Name/Title): _________________________________________

Organization:_____________________________________________________

Site Address:_____________________________________________________

Street_________________ City_______________ Zip Code________________

Phone: ________________________ Fax:__________________________

Email:_______________________________________________________

Note: Failure to submit this form with complete information may result in delays in receiving your final grade.