Student Application
Student's Name ______________________________________ Date _______________
Email address__________________________ Phone___________________
Instructor's Name______________________ Class Meeting Day/Time______________
Course Title____________________________________ Hours Required__________
The student expects the following kinds of learning from the experience: ____________________
_______________________________________________________________________________
Agency's Name, Address, City, Zip____________________________________________________
Name of Agency Supervisor/Coordinator_____________________________Title_______________
Phone__________________Email address___________________Fax ______________________
The agency expects the student to: ___________________________________________________
_______________________________________________________________________________
Days and hours to work ______________________ Total number of hours to be worked _____
Date student will begin_______________________ Date student will end____________________
The agency agrees to provide orientation and training: Yes____ No____
The agency agrees to provide the following resources (check as applicable).
___On-site supervisor ___Space to work ___Critique of student's work
Materials(Specify)________________________Other(Specify)___________________________
I agree to and will uphold the terms of this placement.
Student's signature __________________________________________ Date__________
Supervisor's signature_________________________________________ Date__________
