Placement Begins___________________Ends________________________
Student Last name________________First____________ MI______
Address________________________________________________________________
Telephone___________________
Permanent Address_______________________________________________________
Telephone___________________
Social Security Number_______________________________
Major____________________________
Class Standing
Freshman____ Sophomore____ Junior____ Senior_____ Grad_______
Practicum Placement Agency______________________________________________
Site Supervisor___________________________________________
Title_______________________________________
Address_________________________________________________
Telephone__(____)___________________________
Hours Per Week_________for_______Credit hours of
Sociology 410, and______Sociology 406. Pay? Yes_____No_____
UNIVERSITY Faculty Supervisor__________________________________________________ Telephone_______________________
STUDENT'S LEARNING OBJECTIVES (To be completed by student)
1.______________________________________________________________________________________________________
2.______________________________________________________________________________________________________
3.______________________________________________________________________________________________________
4.______________________________________________________________________________________________________
5.______________________________________________________________________________________________________
STUDENT RESPONSIBILITIES TO FACULTY (Meetings, Reports, Papers, etc.)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Student____________________________________________________________________ Date_____________________
Signature Placement Site Supervisor_____________________________________________________
Date_____________________
Signature Faculty Practicum Superivosr__________________________________________________
Date_____________________
Signature __________________________________________