Student Information
Name:
Address:
Phone:
E-mail:
School Information
Name of Institution:
Instructor's name:
Phone:
E-mail:
Timeframe for Practicum (beginning/ending dates):
Number of hours to be worked:
Student Interest/Availability
Area of interest:
Days and times available for scheduling:
Dates & Times
Weekdays (9-5) (list days available)
Evenings
Weekends
Goals and Objectives for time at JCPL (can be duplicate of school form):